Packed with pills-obstructing duodenal web in the setting of intestinal malrotation:A case report

BACKGROUND The incidence of intestinal malrotation in adults has been reported to only be about 0.2%.Duodenal web as a cause of intestinal obstruction is rare,with an incidence of about 1:20000-1:40000.Furthermore,when described,these conditions are usually seen in early life and very infrequently in adulthood.CASE SUMMARY We report a case of a middle-aged woman with intestinal malrotation who presented with a three-month history of right-sided abdominal pain,early satiety,and a 22-pound weight loss.Patient underwent an esophagogastroduodenoscopy,which demonstrated numerous retained pills in a deformed first portion of the duodenum,concerning for a partial gastric outlet obstruction.An upper gastrointestinal series showed marked distention of the proximal duodenum with retained debris and the presence of a windsock sign,increasing the suspicion of a duodenal web.The patient subsequently underwent surgical intervention where a duodenal web with two lumens was noted and resected,opening the duodenum.There were over 150 pill capsules that were removed.The patient is doing well after this intervention.CONCLUSION Both intestinal malrotation and duodenal webs are infrequently encountered in the adult population.These pathologies can also present with nonspecific abdominal symptoms such as chronic abdominal pain and nausea.Hence,providers might not consider these pathologies in the differential for patients who present with vague symptoms which can lead to delay in management and increased mortality and morbidity.

Molecular analysis of pancreatic cystic neoplasm in routine clinical practice

BACKGROUND Cystic pancreatic lesions consist of a wide variety of lesions that are becoming increasingly diagnosed with the growing use of imaging techniques.Of these,mucinous cysts are especially relevant due to their risk of malignancy.However,morphological findings are often suboptimal for their differentiation.Endoscopic ultrasound fine-needle aspiration(EUS-FNA)with molecular analysis has been suggested to improve the diagnosis of pancreatic cysts.AIM To determine the impact of molecular analysis on the detection of mucinous cysts and malignancy.METHODS An 18-month prospective observational study of consecutive patients with pancreatic cystic lesions and an indication for EUS-FNA following European clinical practice guidelines was conducted.These cysts included those>15 mm with unclear diagnosis,and a change in follow-up or with concerning features in which results might change clinical management.EUS-FNA with cytological,biochemical and glucose and molecular analyses with next-generation sequencing were performed in 36 pancreatic cysts.The cysts were classified as mucinous and non-mucinous by the combination of morphological,cytological and biochemical analyses when surgery was not performed.Malignancy was defined as cytology positive for malignancy,high-grade dysplasia or invasive carcinoma on surgical specimen,clinical or morphological progression,metastasis or death related to neoplastic complications during the 6-mo follow-up period.Next-generation sequencing results were compared for cyst type and malignancy.RESULTS Of the 36 lesions included,28(82.4%)were classified as mucinous and 6(17.6%)as non-mucinous.Furthermore,5(13.9%)lesions were classified as malignant.The amount of deoxyribonucleic acid obtained was sufficient for molecular analysis in 25(69.4%)pancreatic cysts.The amount of intracystic deoxyribonucleic acid was not statistically related to the cyst fluid volume obtained from the lesions.Analysis of KRAS and/or GNAS showed 83.33%[95%confidence interval(CI):63.34-100]sensitivity,60%(95%CI:7.06-100)specificity,88.24%(95%CI:69.98-100)positive predictive value and 50%(95%CI:1.66-98.34)negative predictive value(P=0.086)for the diagnosis of mucinous cystic lesions.Mutations in KRAS and GNAS were found in 2/5(40%)of the lesions classified as non-mucinous,thus recategorizing those lesions as mucinous neoplasms,which would have led to a modification of the follow-up plan in 8%of the cysts in which molecular analysis was successfully performed.All 4(100%)malignant cysts in which molecular analysis could be performed had mutations in KRAS and/or GNAS,although they were not related to malignancy(P>0.05).None of the other mutations analyzed could detect mucinous or malignant cysts with statistical significance(P>0.05).CONCLUSION Molecular analysis can improve the classification of pancreatic cysts as mucinous or non-mucinous.Mutations were not able to detect malignant lesions.

Role of endoscopic ultrasound in pediatric patients: A single tertiary center experience and review of the literature

BACKGROUND Although endoscopic ultrasound(EUS)is now widely available and has an established role in adults,the utility of EUS and EUS-guided fine needle aspiration(EUS-FNA)in pediatrics is insufficiently described compared to adults and is supported by only a few studies.AIM To report the experience of a single tertiary center in the use of EUS and EUS-FNA in a pediatric population and to further assess its safety,feasibility,and clinical impact on management.METHODS A retrospective study of 13 children(aged 18 years or younger)identified from our medical database was conducted.A retrospective review of demographic data,procedure indications,EUS findings,and the clinical impact of EUS on the subsequent management of these patients was performed.RESULTS During the 4-year study period,a total of 13(1.7%)pediatric EUS examinations out of 749 EUS procedures were performed in our unit.The mean age of these 8 females and 5 males was 15.6 years(range:6-18).Six of the 13 EUS examinations were pancreatobiliary(46.1%),followed by mediastinal 2/13(15.4%),peri-gastric 2/13(15.4%),abdominal lymphadenopathy 1/13(7.7%),tracheal 1/13(7.7%)and rectal 1/13(7.7%).Overall,EUS-FNA was performed in 7 patients(53.8%)with a diagnostic yield of 100%.The EUS results had a significant impact on clinical care in 10/13(77%)cases.No complications occurred in these patients during or after any of the procedures.CONCLUSION EUS and EUS-FNA in the pediatric population are safe,feasible,and have a significant clinical impact on the subsequent management;thus avoiding invasive and unnecessary procedures.

Choledochoscope with stent placement for treatment of benign duodenal strictures:A case report

BACKGROUND Endoscopically or fluoroscopically guided dilation is a safe and effective alternative to surgery for patients with benign strictures of the gastric outlet.CASE SUMMARY We describe two cases where a novel approach with a Spyglass~? choledochoscope in assessing the extent of benign duodenal strictures and aiding in placement of duodenal stents for treatment of the strictures. Choledochoscope-guided wire and stent placement was successful in all cases, leading to symptom resolution related to benign duodenal obstruction. No major adverse events were observed.CONCLUSION Choledochoscope-guided assessment and endoscopic therapy is a viable approach in relieving duodenal obstruction, if the conventional combined fluoroscopic and endoscopic methods fail.

Association of trainee participation with adenoma and polyp detection rates

AIM To investigate whether adenoma and polyp detection rates(ADR and PDR, respectively) in screening colonoscopies performed in the presence of fellows differ from those performed by attending physicians alone. METHODS We performed a retrospective review of all patients who underwent a screening colonoscopy at Grady Memorial Hospital between July 1, 2009 and June 30, 2015. Patients with a history of colon polyps or cancer and those with poor colon preparation or failed cecal intubation were excluded from the analysis. Associations of fellowship training level with the ADR and PDR relative to attendings alone were assessed using unconditional multivariable logistic regression. Models were adjusted for sex, age, race, and colon preparationquality. RESULTS A total of 7503 colonoscopies met the inclusion criteria and were included in the analysis. The mean age of the study patients was 58.2 years; 63.1% were women and 88.2% were African American. The ADR was higher in the fellow participation group overall compared to that in the attending group: 34.5% vs 30.7%(P = 0.001), and for third year fellows it was 35.4% vs 30.7%(a OR = 1.23, 95%CI: 1.09-1.39). The higher ADR in the fellow participation group was evident for both the right and left side of the colon. For the PDR the corresponding figures were 44.5% vs 40.1%(P = 0.0003) and 45.7% vs 40.1%(a OR = 1.25, 95%CI: 1.12-1.41). The ADR and PDR increased with increasing fellow training level(P for trend < 0.05).CONCLUSION There is a stepwise increase in ADR and PDR across the years of gastroenterology training. Fellow participation is associated with higher adenoma and polyp detection.

Endoscopic ultrasound in common bile duct dilatation with normal liver enzymes

In recent years,the description of isolated bile duct dilatation has been increasingly observed in subjects with normal liver function tests and nonspecific abdominal symptoms,probably due to the widespread use of high-resolution imaging techniques.However,there is scant literature about the evolution of this condition and the impact of endoscopic ultrasound(EUS)in the diagnostic work up.When noninvasive imaging tests(transabdominal ultrasound,computed tomography or magnetic resonance cholangiopancreatography)fail to identify the cause of dilatation and clinical or biochemical alarm signs are absent,the probability of having biliary disease is considered low.In this setting,using EUS,the presence of pathologic findings(choledocholithiasis,strictures,chronic pancreatitis,ampullary or pancreatic tumors,cholangiocarcinoma),not always with a benign course,has been observed.The aim of this review has been to evaluate the prevalence of disease among nonjaundiced patients without signs of cytolysis and/or cholestasis and the assessment of EUS yield.Data point out to a promising role of EUS in the identification of a potential biliary pathology.EUS is a low invasive technique,with high accuracy,that could play a double cost-effective role:identifying pathologic conditions with dismal prognosis,in asymptomatic patients with negative prior imaging tests,and excluding pathologic conditions and further follow-up in healthy subjects.

Role of virtual reality simulation in endoscopy training

Recent advancements in virtual reality graphics and models have allowed virtual reality simulators to be incorporated into a variety of endoscopic training programmes. Use of virtual reality simulators in training programmes is thought to improve skill acquisition amongst trainees which is reflected in improved patient comfort and safety. Several studies have already been carried out to ascertain the impact that usage of virtual reality simulators may have upon trainee learning curves and how this may translate to patient comfort. This article reviews the available literature in this area of medical education which is particularly relevant to all parties involved in endoscopy training and curriculum development. Assessment of the available evidence for an optimal exposure time with virtual reality simula-tors and the long-term benefits of their use are also discussed.

Race and colorectal cancer screening compliance among persons with a family history of cancer

AIM: To determine compliance to colorectal cancer(CRC) screening guidelines among persons with a family history of any type of cancer and investigate racial differences in screening compliance.METHODS: We used the 2007 Health Information National Trends Survey and identified 1094(27.4%)respondents(weighted population size = 21959672) without a family history of cancer and 3138(72.6%) respondents(weighted population size = 58201479) with a family history of cancer who were 50 years and older. We defined compliance with CRC screening as the use of fecal occult blood testing within 1 year, sigmoidoscopy within 5 years, or colonoscopy within 10 years. We compared compliance with CRC screening among those with and without a family member with a history of cancer. RESULTS: Overall, those with a family member with cancer were more likely to be compliant with CRC screening(64.9% vs 55.1%; OR = 1.45; 95%CI: 1.20-1.74). The absolute increase in screening rates associated with family history of cancer was 8.2% among whites. Hispanics had lowest screening rates among those without family history of cancer 41.9% but had highest absolute increase(14.7%) in CRC screening rate when they have a family member with cancer. Blacks had the lowest absolute increase in CRC screening(5.3%) when a family member has a known history of cancer. However, the noted increase in screening rates among blacks and Hispanics when they have a family member with cancer were not higher than whites without a family history of cancer:(54.5% vs 58.7%; OR = 1.16; 95%CI: 0.72-1.88) for blacks and(56.7% vs 58.7%; OR = 1.25; 95%CI: 0.72-2.18) for Hispanics.CONCLUSION: While adults with a family history of any cancer were more likely to be compliant with CRC screening guidelines irrespective of race/ethnicity, blacks and Hispanics with a family history of cancer were less likely to be compliant than whites without a family history. Increased burden from CRC among blacks may be related to poor uptake of screening among high-risk groups.

Advances in endoscopic retrograde cholangiopancreatography for the treatment of cholangiocarcinoma

Cholangiocarcinoma(CCA) is a malignancy of the bileducts that carries high morbidity and mortality. Patients with CCA typically present with obstructive jaundice, and associated complications of CCA include cholangitis and biliary sepsis. Endoscopic retrograde cholangiopancreatography(ERCP) is a valuable treatment modality for patients with CCA, as it enables internal drainage of blocked bile ducts and hepatic segments by using plastic or metal stents. While there remains debate as to if bilateral(or multi-segmental) hepatic drainage is required and/or superior to unilateral drainage, the underlying tenant of draining any persistently opacified bile ducts is paramount to good ERCP practice and good clinical outcomes. Endoscopic therapy for malignant biliary strictures from CCA has advanced to include ablative therapies via ERCP-directed photodynamic therapy(PDT) or radiofrequency ablation(RFA). While ERCP techniques cannot cure CCA, advancements in the field of ERCP have enabled us to improve upon the quality of life of patients with inoperable and incurable disease. ERCP-directed PDT has been used in lieu of brachytherapy to provide neoadjuvant local tumor control in patients with CCA who are awaiting liver transplantation. Lastly, mounting evidence suggests that palliative ERCP-directed PDT, and probably ERCPdirected RFA as well, offer a survival advantage to patients with this difficult-to-treat malignancy.

Laparoscopy for ventriculoperitoneal shunt implantation and revision surgery

Ventriculoperitoneal shunting(VPS) is a widely accepted technique for the treatment of hydrocephalus. The probability of shunt dysfunction is pretty high throughout life. Laparoscopy has become a valuable tool to perform VPS and treat abdominal complications. An electronic literature search was performed to reveal the published data relating laparoscopy and ventriculoperitoneal shunt in Medline, Embase, Scielo and Lilacs databases. The keywords employed were "laparoscopy" OR "laparoscopic surgery" AND "ventriculoperitoneal shunt" OR "shunt" AND "surgery" OR "implantation" OR "revision" OR "complication". No high quality trials were developed comparing conventional laparotomic incision vs laparoscopic approach. Both approaches have evolved and currently there are less invasive options for laparotomy, like periumbilical small incisions; and for laparoscopy, like smaller and less incisions. Operating room time, blood loss and hospital stay may be potentially smaller in laparoscopic surgery and complications are probably the same as laparotomy. In revision surgery for abdominal complications after VPS,visualization of whole abdominal cavity is fundamental to address properly the problem and laparoscopic approach is valuable once it is safe, fast and much less invasive than laparotomy. Ventriculoperitoneal shunting is a widely accepted technique for the treatment of hydrocephalus. Laparoscopy assisted shunt surgery in selected cases might be a less invasive and more effective option for intrabdominal manipulation. The laparoscopic approach allows a better catheter positioning, lysis of fibrotic bundles and peritoneal inspection as well, without any additional complication.

Recent trends in endoscopic management of achalasia

Esophageal achalasia is a chronic and progressive motility disorder characterized by absence of esophageal body peristalsis associated with an impaired relaxation of lower esophageal sphincter(LES) and usually with an elevated LES pressure, leading to an altered passage of bolus through the esophago-gastric junction. A definitive cure for achalasia is currently unavailable. Palliative treatment options provide only food and liquid bolus intake and relief of symptoms. Endoscopic therapy for achalasia aims to disrupt or weaken the lower esophageal sphincter. Intra-sphincteric injection of botulinum toxin is reserved for elderly or severely ill patients. Pneumatic dilation provides superior results than botulinum toxin injection and a similar mediumterm efficacy almost comparable to that attained after surgery. Per oral endoscopic myotomy is a promising option for treating achalasia, but it requires increased experience and further objective and long-term follow up. This article will review different endoscopic treatments in achalasia, and summarize the short-term and long-term outcomes.

Performing colonoscopy in elderly and very elderly patients:Risks,costs and benefits

Many diagnostic and screening colonoscopies are performed on very elderly patients.Although colonoscopic yield increases with age,the potential benefits in such patients decrease because of shorter life expectancy and more frequent comorbidities.Colonoscopy in very elderly patients carries a greater risk of complications and morbidity than in younger patients,and is associated with lower completion rates and higher likelihood of poor bowel preparation.Thus,screening colonoscopy in very elderly patients should be performed only after careful consideration of potential benefits,risks and patient preferences.On the other hand,diagnostic and therapeutic colonoscopy are more likely to benefit even very elderly patients,and in most cases should be performed if indicated.

Endocytoscopic visualization of squamous cell islands within Barrett's epithelium

AIM: To study the endocytoscopic visualization of squamous cell islands within Barrett's epithelium. METHODS: Endocytoscopy (ECS) has been studied in the surveillance of Barrett's esophagus, with controversial results. In initial studies, however, a soft catheter type endocytoscope was used, while only methylene blue dye was used for the staining of Barrett's mucosa. Integrated type endocytoscopes (GIF-Q260 EC, Olympus Corp, Tokyo, Japan) have been recently developed, with the incorporation of a high-power magnifying endocytoscope into a standard endoscope together with narrow-band imaging (NBI). Moreover, double staining with a mixture of 0.05% crystal violet and 0.1% of methylene blue (CM) during ECS enables higher quality images comparable to conventional hematoxylin eosin histopathological images.RESULTS: In vivo endocytoscopic visualization of papillary squamous cell islands within glandular Barrett's epithelium in a patient with long-segment Barrett's esophagus is reported. Conventional white light endoscopy showed typical long-segment Barrett's esophagus, with small squamous cell islands within normal Barrett's mucosa, which were better visualized by NBI endoscopy. ECS after double CM staining showed regular Barrett's esophagus, while higher magnification (×480) revealed the orifices of glandular structures better. Furthermore, typical squamous cell papillary protrusion, classified as endocytoscopic atypia classification (ECA) 2 according to ECA, was identified within regular glandular Barrett's mucosa. Histological examination of biopsies taken from the same area showed squamous epithelium within glandular Barrett's mucosa, corresponding well to endocytoscopic findings. CONCLUSION: To our knowledge, this is the first report of in vivo visualization of esophageal papillary squamous cell islands surrounded by glandular Barrett's epithelium.

INSTRUCTIONS TO AUTHORS

【正】GENERAL INFORMATION World Journal of Gastrointestinal Endoscopy(World J Gastrointest Endosc, WJGE,online ISSN 1948-5190,DOI:10.4253),is a monthly, open-access(OA),peer-reviewed online journal supported by an editorial board of 400 experts in gastrointestinal endoscopy

MEETING

Events Calendar 2012 January 19-21, 2012 American Society of Clinical Oncology 2012 Gastrointestinal Cancers Symposium San Francisco, CA 3000, United States January 19-21, 2012 2012 Gastrointestinal Cancers Symposium San Francisco, CA 94103, United

Use of portal pressure studies in the management of variceal haemorrhage

Portal hypertension occurs as a complication of liver cirrhosis and complications such as variceal bleeding lead to significant demands on resources. Endoscopy is the gold standard method for screening cirrhotic patients however universal endoscopic screening may mean a lot of unnecessary procedures as the presence of oesophageal varices is variable hence a large time and cost burden on endoscopy units to carry out both screening and subsequent follow up of variceal bleeds. A less invasive method to identify those at high risk of bleeding would allow earlier prophylactic measures to be applied. Hepatic venous pressure gradient (HVPG) is an acceptable indirect measurement of portal hypertension and predictor of the complications of portal hypertension in adult cirrhotics. Varices develop at a HVPG of 10-12 mmHg with the appearance of other complications with HPVG > 12 mmHg. Variceal bleeding does not occur in pressures under 12 mmHg. HPVG > 20 mmHg measured early after admission is a significant prognostic indicator of failure to control bleeding varices, indeed early transjugular intrahepatic portosystemic shunt (TIPS) in such circumstances reduces mortality significantly. HVPG can be used to identify responders to medical therapy. Patients who do not achieve the suggested reduction targets in HVPG have a high risk of rebleeding despite endoscopic ligation and may not derive significant overall mortality benefit from endoscopic intervention alone, ultimately requiring TIPS or liver transplantation. Early HVPG measurements following a variceal bleed can help to identify those at risk of treatment failure who may benefit from early intervention with TIPS. Therefore, we suggest using HVPG measurement as the investigation of choice in those with confirmed cirrhosis in place of endoscopy for intitial variceal screening and, where indicated, a trial of B-blockade, either intravenously during the initial pressure study with assessment of response or oral therapy with repeat HVPG six weeks later. In those with elevated pressures, primary medical prophylaxis could be commenced with subsequent close monitoring of HVPG thus negating the need for endoscopy at this point. All patients presenting with variceal haemorrhage should undergo HVPG measurement and those with a gradient greater than 20 mmHg should be considered for early TIPS. By introducing portal pressure studies into a management algorithm for variceal bleeding, the number of endoscopies required for further intervention and follow up can be reduced leading to significant savings in terms of cost and demand on resources.

Mini-laparoscopy in the endoscopy unit:Safety and outcomes in over one thousand patients

AIM:To investigate the safety of consecutive mini-lapar oscopy guided liver biopsies for the diagnosis and staging of liver diseases. METHODS: In this study we retrospectively analyzed the safety of mini-laparoscopic liver biopsy performed in an endoscopy unit in 1071 patients. We measured the incidence of bleeding and evaluated the management and outcome of bleeding interventions.were viral hepatitis and autoimmune liver disease. 250 patients had macroscopically and histologically proven cirrhosis. 13 patients had no pathological f indings. 33% of all patients had bleeding that required argon plasma coagulation of the puncture site during laparoscopy. Signif icant bleeding occurred more often in patients with liver cirrhosis compared to non-cirrhotic liver dise ases but was effectively treated with laparoscopic coag ulation. CONCLUSION: In conclusion, mini-laparoscopy liver biopsy can be performed safely and effectively in high risk patients with advanced liver disease; mini-lapar osc opy with liver biopsy can be done safely in an endos copy unit.

Endosonography-guided cholangiopancreatography as a salvage drainage procedure for obstructed biliary and pancreatic ducts

Endoscopic ultrasound allows transmural access to the bile or pancreatic ducts and subsequent contrast injection to provide ductal drainage under fluoroscopy using endoscopic retrograde cholangiopancreatography (ERCP)-based techniques.Differing patient specifics and operator techniques result in six possible variant approaches to this procedure,known as endosonography-guided cholangiopancreatography(ESCP). ESCP has been in clinical use for a decade now,with over 300 cases reported.It has become established as a salvage procedure after failed ERCP in the palliation of malignant biliary obstruction.Its role in the management of clinically severe chronic/relapsing pancreatitis remains under scrutiny.This review aims to clarify the concepts underlying the use of ESCP and to provide technical tips and a detailed step-by-step procedural description.

Computed tomography for prediction of esophageal variceal bleeding

This letter to the editor relates to the study entitled“The role of computed tomography for the prediction of esophageal variceal bleeding:Current status and future perspectives”.Esophageal variceal bleeding(EVB)is one of the most common and severe complications related to portal hypertension(PH).Despite marked advances in its management during the last three decades,EVB is still associated with significant morbidity and mortality.The risk of first EVB is related to the severity of both PH and liver disease,and to the size and endoscopic appearance of esophageal varices.Indeed,hepatic venous pressure gradient(HVPG)and esophagogastroduodenoscopy(EGD)are currently recognized as the“gold standard”and the diagnostic reference standard for the prediction of EVB,respectively.However,HVPG is an invasive,expensive,and technically complex procedure,not widely available in clinical practice,whereas EGD is mainly limited by its invasive nature.In this scenario,computed tomography(CT)has been recently proposed as a promising modality for the non-invasive prediction of EVB.While CT serves solely as a diagnostic tool and cannot replace EGD or HVPG for delivering therapeutic and physiological information,it has the potential to enhance the prediction of EVB more effectively when combined with liver disease scores,HVPG,and EGD.However,to date,evidence concerning the role of CT in this setting is still lacking,therefore we aim to summarize and discuss the current evidence concerning the role of CT in predicting the risk of EVB.

Evaluation of appendiceal mucinous neoplasms by curved lineararray echoendoscope:A preliminary study

BACKGROUND Preoperative diagnosis of appendiceal mucinous neoplasms is challenging,and there are few reports regarding the endosonographic characteristics of these neoplasms.AIM To provide a retrospective assessment of the imaging features of appendiceal mucinous neoplasms using endoscopic ultrasound(EUS)by curved linear-array echoendoscope.METHODS A database of all patients with appendiceal mucinous neoplasms who had received EUS examination at our hospital between January 2018 and July 2023 was retrospectively analyzed.The EUS characteristics and patients’clinical data were reviewed.RESULTS Twenty-two patients were included in the study.The linear-array echoendoscope successfully reached the ileocecal region in every patient.In the endoscopic view,we could observe the protrusion in the appendiceal orifice in all patients.A volcano sign was observed in two patients,and an atypical volcano sign was seen in two patients.EUS showed that all 22 lesions were submucosal cystic hypoechoic lesions with clear boundaries.No wall nodules were observed,but an onion-peeling sign was observed in 17 cases.CONCLUSION Linear-array echoendoscope is safe to reach the ileocecal region under the guidance of EUS.Image features on endoscopic and echoendosonograhic views could be used to diagnose appendiceal mucinous neoplasms.