Endoscopic Innovations Research Articles

How to treat diminutive polyps? Do we need more evidence?

How to treat diminutive polyps? Do we need more evidence?

ASGE Technology Committee systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting real-time endoscopic assessment of the histology of diminutive colorectal polyps

In vivo real-time assessment of the histology of diminutive (≤5 mm) colorectal polyps detected at colonoscopy can be achieved by means of an “optical biopsy” by using currently available endoscopic technologies. This systematic review and meta-analysis was performed by the American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee to specifically assess whether acceptable performance thresholds outlined by an ASGE Preservation and Incorporation of Valuable endoscopic Innovations (PIVI) document for clinical adoption of these technologies have been met. We conducted direct meta-analyses calculating the pooled negative predictive value (NPV) for narrow-band imaging (NBI), i-SCAN, and Fujinon Intelligent Color Enhancement (FICE)–assisted optical biopsy for predicting adenomatous polyp histology of small/diminutive colorectal polyps. We also calculated the pooled percentage agreement with histopathology when assigning postpolypectomy surveillance intervals based on combining real-time optical biopsy of colorectal polyps 5 mm or smaller with histopathologic assessment of polyps larger than 5 mm. Random-effects meta-analysis models were used. Statistical heterogeneity was evaluated by means of I2 statistics. Our meta-analyses indicate that optical biopsy with NBI, exceeds the NPV threshold for adenomatous polyp histology, supporting a “diagnose-and-leave” strategy for diminutive predicted nonneoplastic polyps in the rectosigmoid colon. The pooled NPV of NBI for adenomatous polyp histology by using the random-effects model was 91% (95% confidence interval [CI], 88–94). This finding was associated with a high degree of heterogeneity (I2 = 89%). Subgroup analysis indicated that the pooled NPV was greater than 90% for academic medical centers (91.8%; 95% CI, 89-94), for experts (93%; 95% CI, 91-96), and when the optical biopsy assessment was made with high confidence (93%; 95% CI, 90-96). Our meta-analyses also indicate that the agreement in assignment of postpolypectomy surveillance intervals based on optical biopsy with NBI of diminutive colorectal polyps is 90% or greater in academic settings (91%; 95% CI, 86-95), with experienced endoscopists (92%; 95% CI, 88-96) and when optical biopsy assessments are made with high confidence (91%; 95% CI, 88-95). Our systematic review and meta-analysis confirms that the thresholds established by the ASGE PIVI for real-time endoscopic assessment of the histology of diminutive polyps have been met, at least with NBI optical biopsy, with endoscopists who are expert in using this advanced imaging technology and when assessments are made with high confidence.

Endoscopic histological assessment of colonic polyps by using elastic scattering spectroscopy

Elastic-scattering spectroscopy (ESS) can assess invivo and in real-time the scattering and absorption properties of tissue related to underlying pathologies. To evaluate the potential of ESS for differentiating neoplastic from non-neoplastic polyps during colonoscopy. Pilot study, retrospective data analysis. Academic practice. A total of 83 patients undergoing screening/surveillance colonoscopy. ESS spectra of 218 polyps (133 non-neoplastic, 85 neoplastic) were acquired during colonoscopy. Spectral data were correlated with the classification of biopsy samples by 3 GI pathologists. High-dimensional methods were used to design diagnostic algorithms. Diagnostic performance of ESS. Analysis of spectra from polyps of all sizes (N= 218) resulted in a sensitivity of 91.5%, specificity of 92.2%, and accuracy of 91.9% with a high-confidence rate of 90.4%. Restricting analysis to polyps smaller than 1 cm (n= 179) resulted in a sensitivity of 87.0%, specificity of 92.1%, and accuracy of 90.6% with a high-confidence rate of 89.3%. Analysis of polyps 5mm or smaller (n= 157) resulted in a sensitivity of 86.8%, specificity of 91.2%, and accuracy of 90.1% with a high-confidence rate of 89.8%. Sample size, retrospective validation used to obtain performance estimates. Results indicate that ESS permits accurate, real-time classification of polyps as neoplastic or non-neoplastic. ESS is a simple, low cost, clinically robust method with minimal impact on procedure flow, especially when integrated into standard endoscopic biopsy tools. Performance on polyps 5mm or smaller indicates that ESS may, in theory, achieve Preservation and Incorporation of Valuable Endoscopic Innovations performance thresholds. ESS may one day prove to be a useful tool used in endoscopic screening and surveillance of colorectal cancer.

Diagnostic approach to pancreatic cysts.

Diagnosis of pancreatic cysts remains challenging due to limitations of currently available radiologic and endoscopic tools. The diagnostic approach should focus on identifying mucinous and malignant cysts. Mucinous cysts require further differentiation to allow appropriate management. Although the overall rate of malignant pancreatic cysts is low, it remains higher than the general population. MRI with magnetic resonance cholangiopancreatography is the preferred imaging modality for pancreatic cysts. Attempts to improve diagnostic yield of endoscopic ultrasound-guided fine needle aspiration include performing cyst wall cytology and DNA analysis. The 2012 international consensus guidelines for mucinous cystic neoplasm and intraductal papillary mucinous neoplasm are superior to the original 2006 guidelines, although issues include the relatively poor ability to diagnose malignant cysts leading to unnecessary surgeries and the de-emphasis of cyst size. Cyst size remains an important predictor of malignancy. Translational research involving genomics, microRNA, proteomics, and metabolomics holds promise for improved biomarkers. Endoscopic innovations may safely aid in cyst diagnosis. Incremental improvements in pancreatic cyst diagnosis have occurred with new biomarkers and endoscopic tools requiring validation in large-scale studies.

Endoscopy management algorithms: role of cyanoacrylate glue injection and self-expanding metal stents in acute variceal haemorrhage

Mortality from acute variceal bleeding (AVB) has improved markedly over the last 2–3 decades due to increased specialisation and standardisation of medical and endoscopic practice culminating in the production of...

PTU-022 A Novel Photometric Stereo Imaging Sensor For Endoscopy Imaging: Proof Of Concept Studies On A Porcine Model

IntroductionThe American Society of Gastroenterology Endoscopy led Preservation and Incorporation of Valuable Endoscopic Innovations initiative has identified real time polyp diagnosis as one of the next major technology-driven changes in...

Endoscopic innovations to increase the adenoma detection rate during colonoscopy

Up to a quarter of polyps and adenomas are missed during colonoscopy due to poor visualization behind folds and the inner curves of flexures, and the presence of flat lesions that are difficult to detect. These numbers may however be conservative because they mainly come from back-to-back studies performed with standard colonoscopes, which are unable to visualize the entire mucosal surface. In the past several years, new endoscopic techniques have been introduced to improve the detection of polyps and adenomas. The introduction of high definition colonoscopes and visual image enhancement technologies have been suggested to lead to better recognition of flat and small lesions, but the absolute increase in diagnostic yield seems limited. Cap assisted colonoscopy and water-exchange colonoscopy are methods to facilitate cecal intubation and increase patients comfort, but show only a marginal or no benefit on polyp and adenoma detection. Retroflexion is routinely used in the rectum for the inspection of the dentate line, but withdrawal in retroflexion in the colon is in general not recommended due to the risk of perforation. In contrast, colonoscopy with the Third-Eye Retroscope® may result in considerable lower miss rates compared to standard colonoscopy, but this technique is not practical in case of polypectomy and is more time consuming. The recently introduced Full Spectrum Endoscopy™ colonoscopes maintains the technical capabilities of standard colonoscopes and provides a much wider view of 330 degrees compared to the 170 degrees with standard colonoscopes. Remarkable lower adenoma miss rates with this new technique were recently demonstrated in the first randomized study. Nonetheless, more studies are required to determine the exact additional diagnostic yield in clinical practice. Optimizing the efficacy of colorectal cancer screening and surveillance requires high definition colonoscopes with improved virtual chromoendoscopy technology that visualize the whole colon mucosa while maintaining optimal washing, suction and therapeutic capabilities, and keeping the procedural time as low and patient discomfort as optimal as possible.

The good lies so near - invivo diagnosis of colonic polyps.

The good lies so near - invivo diagnosis of colonic polyps.

PTU-033 Meta-Analysis of Flexible Spectral Imaging Colour Enhancement (Fice) in Detection and Characterization of Colorectal Polyps

IntroductionSeveral endoscopic innovations have been developed recently to improve detection and characterization of colorectal polyps. Flexible spectral imaging colour enhancement (FICE) is a form of image enhanced endoscopy which enhances...

Direct observation diverticulectomy for Zenker’s diverticulum carcinoma

Zenker’s diverticulum carcinoma is a rare disease. Recent technological endoscopic innovation has enabled the detection of early stage Zenker’s diverticulum carcinoma. Here we report a case in which a 56-year-old woman was diagnosed with early stage Zenker’s diverticulum carcinoma. Narrow band imaging (NBI) endoscopic examination was useful for diagnosis and identifying the borders of the carcinoma. A successful surgical treatment was performed using direct observation diverticulectomy. A minimally invasive cervical procedure was used, and the area of the carcinoma was confirmed intraoperatively with Lugol’s solution.

Management of abdominal malignancies: updates from the International Association of Surgeons, Gastroenterologists and Oncologists

The World Congress of the International Association of Surgeons, Gastroenterologists and OncologistsBangkok, Thailand, 5–8 December 2012The 22nd World Congress of the International Association of Surgeons, Gastroenterologists and Oncologists was held from 5–8 December 2012 in Bangkok, Thailand. Themed ‘Challenges and Controversies in the Management of Abdominal Diseases: Current Possibility and Future Expectation’, the congress featured ten main topics including: upper GI tract surgery, lower GI tract surgery, hepatic surgery, biliary tract surgery, pancreatic surgery, interventional chemo-immuno-radiotherapy, laparoscopic endoscopic surgery, multidisciplinary approaches, innovation and advanced technology and robotic surgery. Approximately 200 guest speakers were invited to share their experiences and expertise, while 600 abstracts were submitted for oral and poster presentations. In this article, the authors highlight and summarize some of the presentations from this conference.

The State of Simulation in Endoscopy Education: Continuing to Advance Toward Our Goals

Since the introduction of flexible endoscopy in the late 1960s, training programs have faced challenges with endoscopy education. Among these hurdles of traditional endoscopic training are the negative financial impact training poses to a program (in the form of ecreased productivity and lost revenues), the increased isks to patient comfort and safety, as well as the adminstrative responsibility to ensure that competency by rainees is assessed and documented. Over the past deade, these hurdles have become even more challenging s procedure reimbursements have grown increasingly ighter and expectations to document quality and cometency metrics have grown. One potential answer to hese challenges is the use of simulation during training. ith the advent of computer simulation and ex vivo nimal models, there has been renewed interest and reearch in the area of endoscopy simulation with the opes of overcoming some of these hurdles by reducing raining duration, providing a risk-free environment for raining, and allowing for objective measures of skills and ompetency. Despite these research efforts, only a fracion of these hopes have been realized to date.

The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on imaging in Barrett's Esophagus

The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on imaging in Barrett's Esophagus

Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) on the use of endoscopy simulators for training and assessing skill

Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) on the use of endoscopy simulators for training and assessing skill

Tu1739 In-Vivo Optical Diagnosis of Colon Polyp Histology Using High-Definition White Light Endoscopy (HD-WLE): Can the ASGE Preservation of Innovative Endoscopic Innovation (PIVI) Targets Be Met?

The ASGE recently published recommendations for performance characteristics of imaging technologies for the real-time endoscopic assessment of diminutive (≤5mm) colorectal polyps. There is limited data assessing whether HD-WLE alone can meet these thresholds.

Advances in Diagnosis and Treatment of Biliopancreatic Diseases

Management of biliopancreatic diseases has seen great progress in recent years. Innovations in endoscopy have allowed gastroenterologists to assist in the care of many conditions of the biliary tree and pancreas, which were previously only managed surgically. Outcomes for many of these endoscopic interventions are comparable to their surgical counterpart. However, endoscopists taking care of these patients should be well aware of the limitations of their procedures and the advantages of surgery for certain patients. This special issue will address some of the main challenges faced today by physicians taking care of patients with pancreatic and biliary diseases. Endosonography, or endoscopic ultrasound (EUS), which previously was only considered a diagnostic tool, has now emerged as a useful therapeutic technique. In contrast, endoscopic retrograde cholangiopancreatography, or ERCP, has now become mainly a therapeutic tool. Some ERCP techniques have been adopted by endosonographers and allowed interventions for draining bile ducts and peripancreatic fluid collections, previously considered outside the realm of endoscopy. Despite the advances in outcomes and minimal invasiveness of EUS and ERCP-guided interventions, several risks and complications still remain. Pancreatitis is a well-recognized complication of ERCP with a significant incidence that has not been reduced greatly throughout recent years. Numerous studies have looked at ways of decreasing the risk of this dreadful complication. This special issue will discuss and review the problem of post-ERCP pancreatitis, a topic that raises a high level of concern for many who do this procedure, and ways to reduce its risk, especially in patients considered at high risk for developing this complication. Incidental pancreatic cysts continue to pose a diagnostic dilemma for gastroenterologists and surgeons alike. Despite the ability of safely obtaining a tissue sample during EUS examination, the utility of cytopathology in determining the exact nature of these lesions remains limited. More recently, DNA analysis of fluid obtained during aspiration has shown promise in improving the diagnostic accuracy of EUS-FNA. However, the effect of these newer tests in terms of deciding when to observe versus surgically resect in many of these incidental cysts remains to be proven. Pancreatologists agree that a reliable method for determining the nature and prognosis of pancreatic cystic neoplasms is required for improving the management strategy in asymptomatic patients. Abdominal pain is a cardinal symptom of chronic pancreatitis. The effectiveness of medical therapy, in the form of pancreatic enzyme supplementation or octreotide injections, is dismal. Pain relief can certainly be obtained with the use of narcotic medications, but at the cost of significant side effects, such as constipation, sedation, and drug dependence. Endoscopic alternatives for improving pain in chronic pancreatitis include those guided by ERCP, such as intraductal stone removal, stricture dilation, or drainage procedures, and EUS-guided celiac plexus block. This special issue will review the ERCP-guided interventions and discuss the efficacy of EUS-guided celiac plexus neurolysis for the treatment of pain in patients with pancreatic cancer. As advances in endoscopy and surgical innovations are introduced into the field of biliary and pancreatic diseases, many diseases previously requiring complicated surgeries with prolonged recovery are now being managed by minimally invasive techniques. Many of these procedures have a reduced risk when compared to their surgical alternative. However, long-term efficacy and patient risk factors need close consideration when deciding between different management alternatives. Many, if not all, biliary and pancreatic disorders require a close interaction between gastroenterologist and surgeon. The phrase “No man is an island” by John Donne (1572–1631) emphasizes the importance of consensus between specialists and should always be in the minds of those managing patients with biliopancreatic diseases. Fauze Maluf-Filho Jose G. de la Mora Levy Carlos G. Micames

Chronic Cough, Reflux, Postnasal Drip Syndrome, and the Otolaryngologist

Objectives. Chronic cough is a multifactorial symptom that requires multidisciplinary approach. Over the last years, general practitioners refer increasingly more chronic cough patients directly to the otolaryngologist. The aim of this paper is to highlight the issues in diagnosis and management of chronic cough patients from the otolaryngologist perspective. Design. Literature review. Results. Gastroesophageal reflux and postnasal drip syndrome remain one of the most common causes of chronic cough. Better diagnostic modalities, noninvasive tests, and high technology radiological and endoscopic innovations have made diagnosis of these difficult-to-treat patients relatively easier. Multidisciplinary assessment has also meant that at least some of these cases can be dealt with confidently in one stop clinics. Conclusions. As the number of referrals of chronic cough patients to an Ear Nose Throat Clinic increases, the otolaryngologist plays a pivotal role in managing these difficult cases.

ECIRS (Endoscopic Combined IntraRenal Surgery) in the Galdakao-modified supine Valdivia position: a new life for percutaneous surgery?

Percutaneous nephrolithotomy (PNL) is still the gold-standard treatment for large and/or complex renal stones. Evolution in the endoscopic instrumentation and innovation in the surgical skills improved its success rate and reduced perioperative morbidity. ECIRS (Endoscopic Combined IntraRenal Surgery) is a new way of affording PNL in a modified supine position, approaching antero-retrogradely to the renal cavities, and exploiting the full array of endourologic equipment. ECIRS summarizes the main issues recently debated about PNL. The recent literature regarding supine PNL and ECIRS has been reviewed, namely about patient positioning, synergy between operators, procedures, instrumentation, accessories and diagnostic tools, step-by-step standardization along with versatility of the surgical sequence, minimization of radiation exposure, broadening to particular and/or complex patients, limitation of post-operative renal damage. Supine PNL and ECIRS are not superior to prone PNL in terms of urological results, but guarantee undeniable anesthesiological and management advantages for both patient and operators. In particular, ECIRS requires from the surgeon a permanent mental attitude to synergy, standardized surgical steps, versatility and adherence to the ongoing clinical requirements. ECIRS can be performed also in particular cases, irrespective to age or body habitus. The use of flexible endoscopes during ECIRS contributes to minimizing radiation exposure, hemorrhagic risk and post-PNL renal damage. ECIRS may be considered an evolution of the PNL procedure. Its proposal has the merit of having triggered the critical analysis of the various PNL steps and of patient positioning, and of having transformed the old static PNL into an updated approach.

Endoscopic innovation through animal experiments: a new in-vitro platform.

The development in endoscopy has been tremendous since the conceptof inspecting inside human's gastrointestinal tractfirst introduced in 1806. Flexible video endoscope became available with the advances in fiberoptics, image processing and technologies in CCD. In 1970s, the performance of sphincterotomy upon ERCP marked the start of the era of therapeutic endoscopy (1). The concept of en-bloc resection for early gastrointestinal cancers withendoscopic submucosal dissection (ESD) adopted the principles of surgery and applied through endoscopy using innovative instruments (2,3)). Natural Orifices Transluminal Endoscopic Surgery (N.O.T.E.S.) became the next logical step for the development of endoscopic surgery (4). The concept of N.O.T.E.S. is to achieve surgical procedures through the natural orifices of human body without skin incisions. This revolutionary idea, however, cannot be applied to human immediately as the feasibility, safety and effectiveness of these procedures were not completely understand. Animal model became a very important means to establish the achievability of new endoscopic diagnostic and therapeutic procedures (5). These in-vitro experiments, however, were limited by the use of large scale animals toaccommodate large diameter of an ordinary endoscope which is at least 9mm. Establishment of a tumor model in these large scale animal is extremely difficult when compared to nude mice models.

The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps

The PIVI (Preservation and Incorporation of Valuable endoscopic Innovations) initiative is an ASGE program whose objectives are to identify important clinical questions related to endoscopy and to establish a priori diagnostic and/or therapeutic thresholds for endoscopic technologies designed to resolve these clinical questions. Additionally, PIVIs may also outline the data and or the research study design required for proving an established threshold is met. Once endoscopic technologies meet an established PIVI threshold, those technologies are appropriate to incorporate into clinical practice presuming the appropriate training in that endoscopic technology has been achieved. The ASGE encourages and supports the appropriate use of technologies that meet its established PIVI thresholds. The PIVI initiative was developed primarily to direct endoscopic technology development toward resolving important clinical issues in endoscopy. The PIVI initiative is also designed to minimize the possibility that potentially valuable innovations are prematurely abandoned due to lack of utilization and to avoid widespread use of an endoscopic technology before clinical studies documenting their effectiveness have been performed. The following document, or PIVI, is one of a series of statements defining the diagnostic or therapeutic threshold that must be met for a technique or device to become considered appropriate for incorporation into clinical practice. It is also meant to serve as a guide for researchers or those seeking to develop technologies that are designed to improve digestive health outcomes. An ad hoc committee under the auspices of the existing ASGE Technology and Standards of Practice Committees Chairs develops PIVIs. An expert in the subject area chairs the PIVI, with additional committee members chosen for their individual expertise. In preparing this document, evidence-based methodology was employed, using a MEDLINE and PubMed literature search to identify pertinent clinical studies on the topic. PIVIs are ultimately submitted to the ASGE Governing Board for approval, as is done for all Technology and Standards of Practice documents. This document is provided solely for educational and informational purposes and to support incorporating these endoscopic technologies into clinical practice. It should not be construed as establishing a legal standard of care.