Endoscopic Forceps Research Articles

Get a Grip: A Bench Test to Evaluate Endoscopic Forceps Grip Strength on Self-Expanding Metal Stents (SEMS)

Introduction: Self-expanding metal stents (SEMS) are the most commonly-used means of palliation of dysphagia from esophageal and gastric cancers. They are also used routinely for benign stricture dilation. Removal of the stent can prove difficult with tumor overgrowth and breaking of the attached nylon “purse string” used for stent removal/repositioning. To date there have been no comparison studies of forceps to determine the ideal stent removal/repositioning device. Methods: Four commonly used endoscopic forceps were used to evaluate the pounds of pressure allowed before the grip of the forceps failed. Boston Scientific 3.2mm Jumbo, Boston Scientific 2.8mm large, TeleMed 2.4mm Alligator and TeleMed 2.4mm rat tooth forceps were tested on a weighted 90mm Polyflex esophageal SEMS until failure of the clamp was achieved. A 20 pound fishing line was used for a base line. Strength was tested on the “purse string” as well as the proximal metal body of the stent itself. Results: Each forceps grip was evaluated in each method using five runs while on the fishing line for a total of 10 runs; five runs were covered to stimulate the forceps being within the endoscope and five runs uncovered. The mean force for uncovered large forceps, jumbo forceps, rat tooth, and alligator were 1.72, 2.02, 1.98, 2.56 lbs. respectively while covered 2.88, 3.04, 2.54, 1.98 lbs. respectively. There were no outliers using Grubbs' test. There were also no outliers when testing the purse string with the jumbo forceps, rat tooth, and alligator (2.54, 2.38, 1.88 lbs.) but force to failure was significantly greater on the metal stent (3.72, 8.72. 4.74) than on the purse string. The rat tooth forceps had a maximum force of failure at 10.7lbs., with an average of 8.7lbs.; p<.05 when compared against all averages. Conclusion: Significant difference was achieved with the rat tooth forceps when applied to the metal stent itself compared to other forceps.

Successful Emergency Endoscopic Extraction of Gastric Outlet Obstruction Due to Bezoar with Gastric Pneumatosis

Introduction: Gastric pneumatosis (GP) is generally categorized as either emphysematous gastritis (EG) or gastric emphysema (GE). The former has a more ominous presentation, usually requiring a gastrectomy in order to remove necrotic tissue. The breaking and removal of a gastric bezoar causing gastric outlet obstruction (GOO) and subsequent GP is extremely difficult. Here, we present a case of a safe and successful removal of a bezoar with radiologic findings consistent with GP. Presentation Of Case: An 89-year-old man with a history of type 2 diabetes mellitus (DM) presented to our emergency room with a 2-day history of upper abdominal pain, nausea and vomiting. CT scan of the abdomen showed a dilated stomach with significant fluid collection, GOO and GP due to a 42x40 mm mass composed of fat and air densities. Emergency endoscopy revealed two gastric bezoars, one of which was incarcerated in the pyloric region. We used various endoscopic devices to successfully break and remove the bezoar endoscopically. Follow-up endoscopy confirmed that the gastric bezoar had been completely removed.Figure 1Figure 2Figure 3Discussion: Gastric bezoars presenting with GOO are generally too large to extract and too hard to break.There are several reports of bezoars which required surgical removal or dissolution therapy using Coca-Cola.On the other hand, reports of successful endoscopic removal of bezoars presenting with GOO and GP are extremely scarce.In this case, the size of the bezoar (over 40mm) made it necessary to break it using endoscopic snares, forceps and nets. Patient was able to avoid surgery through repeated endoscopic procedures.History of gastrectomy, old age, and type 2 DM are risk factors of phytobezoars which are composed of undigested food.Endoscopic treatment is preferable to surgery not only because it is less invasive, but also because of the possibility of recurrence of post-gastrectomy phytobezoars.GP in this case was believed to be GE, as 1) endoscopy findings showed several gastric ulcers due to mucosal injury arising from intraluminal high pressure resulting from obstruction, 2) the patient was in no apparent distress and 3) CT scan did not show evidence of ischemia. We believe that endoscopic therapy should be attempted before surgery in cases of GE. Conclusion: Endoscopic treatment may be a safe and viable option for the extraction of gastric bezoars presenting with GOO and GP when the patient's condition is stable and there is no evidence of ischemia.

Safety and Efficacy of Self Expandable Metal Stents (SEMS) in Benign Strictures

Introduction: This study was performed to test the safety and efficacy of short term fully covered self expandable metal stents (SEMS) in benign strictures of the duodenum, pylorus and anastomoses Methods: Upper endoscopy with through the scope fully covered metal stents (Taewong Corporation) was performed in 19 patients with benign strictures. The location of stricture was; duodenum 4, pylorus 6, gastric bypass anastomoses 6, Whipple with gastrojejunostomy and efferent limb obstruction 3. The pyloric and duodenal stents were left in place for 2 weeks unless jaundice developed (1 patient). The gastric bypass and Whipple gastrojejunostomy stents were left in place for 6 weeks. Stents were removed using standard upper endoscope and Rat Tooth Forceps unless stents migration occurred. 4 point gastric outlet obstruction scoring system was used to record improvement. At least 1 point improvement in score was considered success. Median follow up was 12 months, minimum 4 months, maximum 24 months. Results: Stents were placed successfully in all 19 patients. 18 mm diameter stents were placed in 11 patients, 20 mm diameter stents were placed in 8 patients.10 patients had stent migration. Proximal migration into the stomach from duodenum occurred in 2 patients, distal migration occurred in 8 patients. 2 stents required removal through double balloon enteroscopy. The remaining 6 stents passed spontaneously without consequences. All patients had minimum of 1 point improvement in gastric outlet obstruction score, mean 2 points improvement. 16 patients were able to tolerate soft diet after stent removal. 3 patients were able to tolerate full liquid diet. 2 patients had late recurrence of symptoms, 6 and 12 months later, both were treated with repeat stenting (pyloric stenosis 1, gastric bypass 1). 1 patient developed rising LFTs after duodenal stent placement, this stent was removed on day 6, patient continued to tolerate soft diet after stent removal. No other complications were encountered. Conclusion: Through the scope fully covered SEMS appear to be safe and effective in management of benign strictures in upper GI tract. Stent migration is a limitation, however this can be prevented by suturing the stent.

Endoscopic diagnosis and resection of pharyngeal papillomas

Objective To evaluate the diagnostic and therapeutic effect of endoscopy on pharyngeal papillomas. Methods Data of patients with pharyngeal papillomas diagnosed and treated by endoscopy between March 2009 and December 2014 were analyzed retrospectively, including dissection, treatment and follow-up results. Results The rate of endoscopic diagnosis of pharyngeal papillomas was 0.9%(65/6 927). Endoscopic biopsy forceps resection was performed successfully in 54 patients. Other patients(n=11) were treated by endoscopic snare resection. There was hemorrhage of different degrees after resection. Argon hemostasis was used in 6 patients for errhysis after resection. Supportive treatment was not given and no severe hemorrhage or death was seen. A total of 41 patients were followed up and endoscopic examination was performed 2 months later. Pharyngeal papillomas were found again at the same site in two patients and endoscopic biopsy forceps resection was performed. Pharyngeal papillomas were not found in these two patients in the next endoscopic examination. Conclusion Endoscopy is a safe and effective diagnosis and treatment method for pharyngeal papillomas. Key words: Endoscopy; Therapeutic endoscopy; Papilloma; Pharynx

Correlation between endoscopic forceps biopsies and endoscopic mucosal resection with endoscopic ultrasound in patients with Barrett's esophagus with high-grade dysplasia and early cancer.

Patients with Barrett's esophagus (BE) and high-grade dysplasia (HGD) or intramucosal cancer (IMC) on endoscopic forceps biopsies are referred to endoscopic therapy even though forceps biopsies do not reflect the disease extent accurately. Endoscopic mucosal resection (EMR) and endoscopic ultrasound (EUS) are frequently used for staging prior to endoscopic therapy. Our aims were to evaluate: (1) if endoscopic forceps biopsies correlated with EMR histology in these patients; (2) the utility of EUS compared to EMR; and (3) if accuracy of EUS varied based on grade of differentiation of tumor. This is a retrospective review of patients referred to endoscopic therapy of BE with HGD or early esophageal adenocarcinoma (EAC) who underwent EMR from 2006 to 2011. Age, race, sex, length of Barrett's segment, hiatal hernia size, number of endoscopies and biopsy results and EUS findings were abstracted. A total of 151 patients underwent EMR. In 50% (75/151) of patients, EMR histology was consistent with endoscopic forceps biopsy findings. EMR resulted in change in diagnosis with upstaging in 21% (32/151) and downstaging in 29% (44/151). In patients with HGD on EMR, EUS staging was T0 in 74.1% (23/31) but upstaged in 25.8% (8/31). In patients with IMC on EMR, EUS findings were T1a in 23.6% (9/38), upstaged in 18.4% (7/38) and downstaged in 57.8% (22/38). EUS accurately identified EMR histology in all submucosal cancers. Grade of differentiation was reported in 24 cancers on EMR histology. There was no correlation between grade and EUS staging. EUS is of limited utility in accurate staging of BE patients with HGD or early EAC. Endoscopic forceps biopsy correlated with EMR findings in only 50% of patients. Irrespective of the endoscopic forceps biopsy results, all BE patients with visible lesions should be referred to EMR.

A case of carcinoma in adenoma of the duodenal minor papilla successfully treated by endoscopic mucosal resection

Over a 5-year period (1985 to 1990), 25 patients (11 men and 14 women, median age 68) with adenomatous tumors of the papilla of Vater judged to be benign by endoscopic appearance and forceps biopsy were included in this study. All patients had de novo tumors except for two patients who had recurrent adenomas after local surgical excision. Presenting symptoms included pain (19 patients), jaundice (9 patients), and pancreatitis (4 patients). ERCP showed bile and pancreatic duct dilation in 20 patients (6 with stones) and 2 patients, respectively. The adenoma and the papilla of Vater were excised using a standard polypectomy snare (snare papillectomy). Procedure-related complications included bleeding in two patients and acute pancreatitis in three patients. No deaths occurred. Histologic analysis showed benign adenoma with mild to moderate dysplasia in 18 patients and severe dysplasia in 1 patient. Two patients with evidence for intraductal tumor extension on ERCP were referred for surgery. Six patients had recurrences at a median follow-up of 37 months (range, 7 to 79 months), of whom one had intraductal tumor spread and underwent pancreatoduodenectomy. Five patients were re-treated endoscopically: one ultimately required surgery.

Clinical features of negative pathologic results after gastric endoscopic submucosal dissection.

Endoscopic submucosal dissection (ESD) is widely used for the treatment of gastric superficial neoplasms. Negative pathologic results after ESD can confuse the endoscopists and patients. The aim of this study was to evaluate the reasons for and the factors associated with negative pathologic results after ESD. From December 2008 to July 2015, a total of 1379 lesions diagnosed as definite dysplasia or adenocarcinoma by endoscopic forceps biopsy (EFB) were removed with an ESD procedure. The initial endoscopic and pathologic findings were analyzed. The incidence of negative pathology after ESD was 2.0% (28/1379). Compared with positive pathologic lesions, negative pathologic lesions were smaller and had less surface area (P<0.001). The reasons for negative pathologic lesions after ESD were complete removal by EFB (n=20), over-estimations of the EFB specimen (n=5), and different ESD site (n=3). Small tumor size and surface area are associated with negative pathologic results after ESD. When negative pathologic results are reported after ESD, we should review the previous endoscopic biopsy tissue specimen and compare the previous EFB site to the ESD site. Thereafter, regular endoscopic examination of the lesion is needed.

Risk factors for missed diagnosis of high-grade gastric neoplasia

Objective To evaluate the potential risk factors for missed diagnosis of gastric high-grade neoplasia(HGN) lesion on the basis of endoscopic features. Methods A total of 43 lesions which were initially diagnosed as HGN without cancer by forceps biopsy and later underwent endoscopic submucosal dissection(ESD) were included from November 2011 to April 2015. According to histology of ESD specimens, they were divided into HGN group and the cancer group, and their endoscopic characteristics were compared. Results There was no significant difference in the age(t=6.124, P=0.101), gender distribution(χ2=0.189, P=0.663), lesion location(χ2=1.008, P=0.909), lesion morphology(χ2=0.537, P=0.765), mucosal nodular lesions surface(χ2=0.599, P=0.439)or biopsy times(u=1.833, P=0.591) between the HGN group and cancer group. Univariate analysis showed that there were significant differences in size(t=3.324, P=0.016), a red change of the mucosal surface(χ2=11.882, P<0.001)and mucosal ulceration(χ2=5.635, P=0.018)between the two groups. In the multivariate analysis, size larger than 20 mm(OR=2.041, 95%CI: 1.023-5.682, P<0.001) and mucosal ulceration(OR=3.764, 95%CI: 1.223-9.431, P<0.001) were independent risk factors for the missed diagnosis of cancer on the HGN by forceps biopsy. Conclusion For biopsy-proven HGN gastric mucosa lesions, whose sizes are larger than 20 mm or with superficial mucosal ulcer, we need to alert to the possible missed diagnosis of cancer. Due to the limited sample size and selection bias of retrospective study sample, further researches are still needed. Key words: Gastric cancer; High-grade neoplasia; Endoscopic forceps biopsy; Endoscopic submucosal dissection

Yield and Clinical Utility of Next-Generation Sequencing in Selected Patients With Lung Adenocarcinoma

BackgroundNext-generation sequencing is available for assessing genomic alterations in non–small-cell lung cancer (NSCLC), although the performance characteristics and clinical utility has not been well characterized. This technique can be used to sequence hundreds of known cancer-associated genes. Our aim was to investigate the diagnostic success and clinically relevant results of extensive sequencing in NSCLC patients. Patients and MethodsA case series of 49 NSCLC patients was used to determine the success of extended next-generation sequencing, record genomic alterations, and evaluate clinical utility. Data were collected in a retrospective review. Sequencing was performed using a hybridization capture of 3320 exons from 236 cancer-related genes and 47 introns of 19 genes applied to ≥50 ng of DNA and sequenced to high, uniform coverage of 622 times. ResultsSequencing was successful in 29 of 32 (91%) surgical/excisional specimens, and 12 of 17 (71%) nonsurgical specimens including an endoscopic forceps biopsy, core needle biopsies, fine-needle aspirates, and effusion cytologies. All 5 transthoracic core needle biopsies failed. A total of 179 genomic alterations (average 4.37 per tumor) were found. A total of 63 were clinically relevant (average 1.54 per tumor). The most frequently mutated genes were tumor protein p53, cyclin-dependent kinase inhibitor 2A, megalencephalic leukoencephalopathy with subcortical cysts 1, rapamycin-insensitive companion of mammalian target of rapamycin, epithelial growth factor receptor, SWI/SNF Related, Matrix Associated, Actin Dependent Regulator Of Chromatin, Subfamily A, Member 4, cyclin-dependent kinase inhibitor 2B, phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic subunit α, Kirsten rat sarcoma viral oncogene homolog, Erb-B2 receptor tyrosine kinase 2, Serine/Threonine Kinase 11, and NK2 Homeobox 1. Sequencing results led to a change in management in 7 of 49 cases (14.3%). ConclusionExtended next-generation sequencing was performed successfully in 41 (83.7%) cases of NSCLC using a range of pathology specimens. Testing had the potential to affect treatment decisions in selected patients.

579 Risk Stratification of Patients With Gastric Indefinite for Dysplasia; Is Endoscopic Follow-Up With Recurrent Biopsy Enough for a Definite Diagnosis of Gastric Indefinite for Dysplasia?

The diagnosis “indefinite for dysplasia” (IND) represents a heterogeneous histological group, and is used by pathologists when a diagnosis of genuine dysplasia cannot be made. However, there are no definite guidelines for the management of gastric IND on endoscopic forceps biopsy (EFB). Therefore, the aim of this study was to evaluate the clinical outcomes of gastric IND on EFB and predictable factors for gastric neoplasm.

Treatment Strategy of Gastric Adenoma

Gastric adenoma is a precancerous lesion. While some adenomas regress spontaneously, others progress as invasive carcinomas. Simple follow-up of gastric adenoma may be possible considering the possibility of spontaneous regression. However, several studies have reported discrepancies between the results of endoscopic forceps biopsies and post-resection biopsies. These studies showed that the pathological findings are more severe in biopsies performed after endoscopic resections. We suggest that endoscopic resections should be planned for cases of gastric adenoma. After endoscopic resection, regular endoscopic surveillance and Helicobacter pylori eradication may reduce the occurrence of gastric cancer. (Korean J Med 2016;90:217-223)

操作妨害機能を用いた鉗子操作技術評価に関する研究

Against the background of increasing the number of cases of endoscopic surgery, more effective training system has been requested from doctors. By the way, it is important to assess the proficiency level of operating an endoscopic forceps. Then, this study aims to develop an assessment system for the operation skill of endoscopic forceps. In our system, the operation skill of endoscopic forceps is assessed by adding the disturbance to a trainee who is practicing the forceps operation. Three doctors were employed as the test subjects of this study and the differences in their proficiency levels were confirmed in our experiments.

Balloon Dilatation Biopsy of the Biliary Stricture through the Percutaneous Transhepatic Biliary Drainage Tract: Feasibility and Diagnostic Accuracy

경피적 미세흡인생검술(fine needle aspiration biopsy; 이하 Purpose: To evaluate the feasibility and diagnostic accuracy of the balloon dilatation biopsy for the biliary stricture through the percutaneous transhepatic biliary drainage (PTBD) tract. Materials and Methods: The study included 35 patients who underwent balloon dilatation biopsy for the biliary stricture through the PTBD tract. Balloon dilatation was done with a balloon catheter of 10-mm or 12-mm diameter. Soft tissue adherent to the retrieved balloon catheter and soft tissue components separated by gauze filtration of evacuated bile were sampled for histopathologic examination. The results were compared with the final diagnosis which was made by clinical and imaging follow-up for mean 989 days (n = 34) and surgery with histopathologic examination (n = 1). Procedure-related complications and diagnostic accuracy were assessed. Results: Tissues suitable for histopathologic examination were obtained in 31 out of 35 patients (88.6%). In 3 patients, self-limiting hemobilia was noted. No major complication was noted. The sensitivity, specificity, diagnostic accuracy, positive and negative predictive values for diagnosis of malignant stricture were 70.0%, 100%, 90.3%, 100%, and 87.5%, respectively. Conclusion: Balloon dilatation biopsy of the biliary stricture through the PTBD tract is a feasible and accurate diagnostic method. It can be a safe alternative to the endoscopic retrograde cholangiography biopsy or forceps biopsy through the PTBD tract. Index terms Radiology, Interventional Biopsy Bile Ducts Cholangiocarcinoma

Novel and safer endoscopic cholecystectomy using only a flexible endoscope via single port.

To apply the laparoscopic and endoscopic cooperative surgery concept, we investigated whether endoscopic cholecystectomy could be performed more safely and rapidly via only 1 port or not. Two dogs (11 and 13-mo-old female Beagle) were used in this study. Only 1 blunt port was created, and a flexible endoscope with a tip attachment was inserted between the fundus of gallbladder and liver. After local injection of saline to the gallbladder bed, resection of the gallbladder bed from the liver was performed. After complete resection of the gallbladder bed, the gallbladder was pulled up to resect its neck using the Ring-shaped thread technique. The neck of the gallbladder was cut using scissor forceps. Resected gallbladder was retrieved using endoscopic net forceps via a port. The operation times from general anesthetizing with sevoflurane to finishing the closure of the blunt port site were about 50 min and 60 min respectively. The resection times of gallbladder bed were about 15 min and 13 min respectively without liver injury and bleeding at all. Feed were given just after next day of operation, and they had a good appetite. Two dogs are in good health now and no complications for 1 mo after endoscopic cholecystectomy using only a flexible endoscope via one port. We are sure of great feasibility of endoscopic cholecystectomy via single port for human.

Foreign body presenting as a duodenal mass: Case report and literature review

Importance: An abnormal clinical presentation of foreign body ingestion and its therapeutic approach. Review of the literature to determine rate of perforation along the gastrointestinal tract by foreign body ingestion and to identify appropriate diagnosis and treatment of ingested foreign bodies in the duodenum. Observations: A case report of a 57-year-old female presenting with abdominal pain, chest pain, and headaches for two days. With computed tomography imaging, findings of an intraluminal mass in the duodenum and retroperitoneal air were identified, leading to suspicion of a perforated duodenal malignancy. On endoscopic ultrasound, a toothpick was identified protruding through the wall of the third portion of the duodenum, which was removed by upper endoscopic forceps. A review of the literature yielded 236 cases of foreign body perforation of the gastrointestinal tract between the years 2000 to 2015 in adults 18 years and older. Perforation rate of the small bowel was highest at 39.8% followed by the duodenum 22%, colon 20.3%, sigmoid 5.5%, and unidentified site 1.7%. Literature analysis for therapeutic options for gastrointestinal injury by foreign body ingestion included endoscopy, laparotomy, or laparoscopy. A diagnostic therapeutic algorithm for duodenal foreign body ingestion was created. Conclusions: Ingested foreign bodies can present with a variety of clinical symptoms. Thus, they should be considered as part of a differential diagnosis for cases with gastrointestinal symptoms without clear etiology. Even with imaging studies, foreign body ingestion can be difficult to diagnose initially. Sharp objects, especially toothpicks, have an increased rate of perforation of the gastrointestinal tract and have a high associated morbidity and mortality. As such, prompt diagnosis and management are necessary to improve outcomes.

Impact of Intraoperative Pancreatoscopy with Intraductal Biopsies on Surgical Management of Intraductal Papillary Mucinous Neoplasm of the Pancreas

Because of its known malignant potential, precise histologic diagnosis of intraductal papillary mucinous neoplasm of the pancreas (IPMN) during intraoperative pancreatoscopy (IOP) is essential for complete surgical resection. The impact of IOP on perioperative IPMN patient management was reviewed over 20 years of practice at Cliniques universitaires Saint-Luc, Brussels, Belgium. Among 86 IPMN patients treated by pancreatectomy between 1991 and 2013, 21 patients had a dilated main pancreatic duct enabling IOP and were retrospectively reviewed. The IOP was performed using an ultrathin flexible endoscope and biopsy forceps, and specimens of all suspicious lesions underwent frozen section examination. Complete IOP with intraductal biopsies was easily and safely performed in 21 patients, revealing 8 occult IPMN lesions. In 5 cases (23.8%), initially planned surgical resection was modified secondary to IOP: 3 for carcinoma in situ and 2 for invasive carcinoma. The postoperative morbidity rate at 3 months was 25.0% (5 of 20); 1 patient died from septic shock postoperatively and was excluded. Median follow-up was 93 months (range 13 to 248 months). Nineteen of 21 patients were still alive and free of disease at last follow-up (90.5%); there was 1 patient with invasive carcinoma at initial pathology (pT3 N1) who died of pulmonary recurrence 21 months after surgery. Intraoperative pancreatoscopy of the main pancreatic duct combined with intraductal biopsies plays a significant role in the surgical management of IPMN patients and should be used in all patients presenting a sufficiently dilated main pancreatic duct.

How Commonly Is the Diagnosis of Gastric Low Grade Dysplasia Upgraded following Endoscopic Resection? A Meta-Analysis.

Gastric dysplasia is a well-known precancerous lesion. Though the diagnosis of gastric low grade dysplasia (LGD) is generally made from endoscopic forceps biopsy (EFB), the accuracy is doubtful after numerous EFB-proven gastric LGD were upgraded to gastric high grade dysplasia (HGD) or even carcinoma (CA) by further diagnostic test with the procedure of endoscopic resection (ER). We aimed to evaluate the upgraded diagnosis rate (UDR) and the risk factors by ER in EFB-proven gastric LGD lesions. Two investigators independently searched studies reporting the UDR by ER in EFB-proven gastric LGD lesions from databases and analyzed the overall UDR, HGD-UDR and CA-UDR. The pooled UDR by ER in EFB-proven gastric LGD lesions was 25.0% (95% CI, 20.2%-29.8%), made up of HGD-UDR and CA-UDR by rates of 16.7% (95% CI, 12.8%-20.6%) and 6.9% (95% CI, 4.2%-9.6%) respectively. Lesion size larger than 2 cm, surface with depression and nodularity under endoscopic examinations were the major risk factors associated with UDR. In conclusion, one quarter of EFB-proven gastric LGD lesions will be diagnosed as advanced lesions, including gastric HGD (16.7%) and gastric CA (6.9%) by ER. The diagnosis of those LGD lesions with an endoscopic diameter larger than 2cm, and depressed or nodular surface are more likely to be upgraded after ER.

Unsedated transnasal esophagoscopy for monitoring therapy in pediatric eosinophilic esophagitis

Unsedated transnasal endoscopy (TNE) is safer and less costly than sedated EGD. The aim of this study was to evaluate the performance of TNE with biopsies in monitoring the esophageal mucosa of pediatric patients with eosinophilic esophagitis. Patients between 8 and 17 years of age with eosinophilic esophagitis and their parents were enrolled. Unsedated TNE was performed. A 2.8-mm (1.2-mm channel) or a 4-mm flexible bronchoscope (2-mm channel) was used, and esophageal biopsy specimens were obtained. Biopsy specimen analysis, duration, adverse events, and billing charges of TNE were assessed. Immediately after TNE and a minimum of 2 weeks later, a modified Group Health Association of America 9 survey and a preference questionnaire were completed, respectively. Twenty-one of 22 enrolled patients underwent TNE. TNE was performed with no serious adverse events. Histopathological analysis revealed 0 eosinophils per high-power field (n = 12), fewer than 15 eosinophils per high-power field (n = 4), and more than 15 eosinophils per high-power field (n = 5). The total epithelial surface area of mucosal biopsy samples from either TNE Forceps (1.2 mm or 2 mm biopsy channel forceps) compared with those obtained during the subject's previous EGD by using standard endoscopic forceps was not statistically different (P = .308 [1.2 mm]/P = .492 [2 mm]). All parents and 76.2% of subjects would undergo the TNE again. TNE was preferred over EGD by 85.7% of parents and 52.4% of subjects. The modified Group Health Association of America 9 survey revealed a high degree of satisfaction (average, 43.19 ± 2.6; maximum score, 45). Charges associated with TNE were 60.1% lower than for previous EGDs. Unsedated TNE is an effective, lower-cost procedure for monitoring the esophageal mucosa of children with eosinophilic esophagitis.

Ampullary Adenoma Treated by Endoscopic Double-Snare Retracting Papillectomy.

We report herein improved methods for the safe and successful completion of endoscopic papillectomy (EP). Between January 2008 and November 2011, 12 patients underwent double-snare retracting papillectomy for the treatment of lesions of the major duodenal papilla. The main outcomes were en bloc resection rates, pathological findings, and adverse events. All of the patients (mean age, 60.1 years; range, 38 to 80 years) were diagnosed with ampullary adenoma by endoscopic forceps biopsies prior to endoscopic snare papillectomy. En bloc resection by double-snare retracting papillectomy was successfully performed for all lesions (median size, 12.3 mm), comprising six tubular adenomas, one tubulovillous adenoma, three cases of epithelial atypia, one hamartomatous polyp, and one case of duodenitis with regenerative change. Significant hemorrhage and pancreatitis were observed in one case after EP. Adenoma recurrence occurred in three patients during follow-up (median, 28.5 months) at a mean interval of 2 months postoperatively (range, 1 to 3 months). No serious adverse events were observed. Double-snare retracting papillectomy is effective and feasible for treating lesions of the major duodenal papilla. Further treatment experience, including a single-arm phase II study, needs to be accumulated before conducting a randomized controlled study.

PTU-007 Needle knife mucosal incision to obtain deep biopsies of submucosal lesions along the gi tract – efficacy and safety

<h3>Introduction</h3> Submucosal lesions in the GI (gastro-intestinal) tract are difficult to diagnose. The diagnostic yield from mucosal biopsies using standard endoscopic forceps (bite-on-bite technique) and from EUS guided FNA is limited. Endoscopic submucosal dissection and surgery are high risk methods of tissue acquisition as the majority of these lesions are benign. Early diagnosis of a benign lesion will reduce the need for regular surveillance. In some instances, the diagnosis will also help in the endoscopic treatment of symptomatic benign lesions. We therefore evaluated the diagnostic yield achieved from mucosal incision-assisted biopsies of various submucosal lesions in a series of 10 patients. <h3>Method</h3> A 20 month retrospective study of all patients who had mucosal incision-assisted biopsy of submucosal GI lesions. In case of upper GI lesions, EUS assessment preceded the needle knife mucosal incision. In lesions with a higher risk of bleeding, the defect was closed with clips. For all patients, we recorded the size, site and histopathological findings of the lesions and any procedure-related complications. <h3>Results</h3> 10 submucosal lesions (size varying from 10–30 mm) were biopsied using prior mucosal incision between May 2013 and Dec 2014. Two were colonic, 3 duodenal, 2 in the stomach and 3 in the oesophagus. Adequate tissue for diagnosis was obtained in all except one small oesophageal lesion. Histological diagnosis and site is shown in the Table 1. One patient had delayed bleeding which settled following endoscopic treatment. There were no other complications, immediate or late. <h3>Conclusion</h3> Mucosal incision-assisted biopsy is effective in the diagnosis of submucosal GI lesions with a high yield. It also appears safe. Although significant bleeding and perforation are possible complications, only one case of delayed bleeding, endoscopically treated, occurred in this series. Patients with asymptomatic benign lesions can be therefore be reassured with no need for further surveillance whilst appropriate treatment (endoscopic or surgical) can be rapidly arranged for malignant or symptomatic benign lesions. <h3>Disclosure of interest</h3> None Declared.