Passage Of Endoscope Research Articles

Assessment of intestinal luminal stenosis and prediction of endoscopy passage in Crohn’s disease patients using MRI

BackgroundCrohn’s disease (CD) is an inflammatory disease of the gastrointestinal tract. The disease behavior changes over time, and endoscopy is crucial in evaluating and monitoring the course of CD. To reduce the economic burden of patients and alleviate the discomfort associated with ineffective examination, it is necessary to fully understand the location, extent, and severity of intestinal stenosis in patients with CD before endoscopy. This study aimed to utilize imaging features of magnetic resonance enterography (MRE) to evaluate intestinal stenosis in patients with CD and to predict whether endoscopy could be passed.MethodsMRE data of patients with CD were collected, while age, gender, disease duration, and laboratory test parameters were also gathered. Two radiologists analyzed the images and assessed whether endoscopy could be passed based on the imaging performance. Imaging features of MRE were analyzed in groups based on endoscopy results.ResultsThe readers evaluated the imaging performance for 86 patients to determine if endoscopy could be passed and performed a consistency test (compared between two readers k = 0.812, p = 0.000). In the univariate analysis, statistical differences were observed in the degree of T1WI enhancement, thickness of the intestine wall at the stenosis, and diameter of the upstream intestine between the two groups of whether endoscopy was passed. In multivariate logistic regression, the diameter of the upstream intestine was identified to be an independent factor in predicting whether endoscopy was passed or not (OR = 3.260, p = 0.046).ConclusionsThe utilization of MRE signs for assessing the passage of an endoscope through the narrow segment revealed that the diameter of the upstream intestine emerged as an independent predictor of endoscopic passage. Before performing an endoscopy, MRE can aid in evaluating the passage of the endoscope.Critical relevance statementThis retrospective study explored the imaging features of MRE to evaluate intestinal stenosis in patients with Crohn’s disease and determined that the diameter of the upstream intestine of the stenotic segment was an independent predictor in assessing endoscopic passage.Key points• Endoscopy is crucial in evaluating and monitoring the course of Crohn’s disease.• The diameter of the upstream intestine of the stenotic segment was an independent predictor in assessing endoscopic passage.• MRE can aid in evaluating the passage of the endoscope in stenotic segments of Crohn’s disease.Graphical

Partial duodenectomy with seromyotomy by the "lift-and-cut" method for superficial nonampullary duodenal epithelial tumors: A novel technique.

The therapeutic strategy for superficial nonampullary duodenal epithelial tumors remains controversial. We developed a novel surgical technique for superficial nonampullary duodenal epithelial tumors. We report the initial two cases managed with this method. We endoscopically confirmed the tumor location and circumferentially incised the seromuscular layer of the duodenum along it. After circumferential seromyotomy, the submucosal layer was expanded by endoscopic insufflation, and the target lesion was sufficiently lifted. The submucosal layer, including the target lesion, was stapled and resected after confirming the absence of problems with endoscopic passage. The seromuscular layer was continuously sutured to bury and reinforce the stapler line. Single-incision laparoscopic surgery was performed in one case. The resected specimens measured 52 × 32 mm and 50 × 26 mm with negative surgical margins. Both patients were discharged without complications and demonstrated no evidence of stenosis. Compared with previously reported procedures, this method of partial duodenectomy with seromyotomy for superficial nonampullary duodenal epithelial tumors is promising, simple, and safe.

Predictors of clinical response of esophageal dilatations in pediatric population

IntroductionEsophageal strictures are a common condition, and pediatric surgeons confront them regularly. Despite being performed very frequently, there ared not studies that clearly identify prognostic factors for pediatric patients. MethodsMedical records of the children who were taken to esophageal dilatation due to strictures from January 2015 to December 2018 were reviewed. Statistical analysis was performed to establish prognostic factors. ResultsSix hundred sixty-three procedures were performed in 111 patients. The majority of patients had antecedent of esophageal atresia 56%, corrosive stricture in 24%, idiopathic 11%, and Gastroesophageal Reflux (GER) in 9%. The effectiveness of the dilatations was evaluated against three parameters: Dysphagia 0 or 1 in the last assessment 82%. Discharge from dilatation protocol 64%, and no need for surgery 74%. The Global effectiveness was determined by fulfilling the three previous outcomes and was of 49%. The complication rate was 1.9%, being esophageal perforation the most frequent. The statistically significant predictors for the ineffective dilations were airway compromise and history of feeding surgery. The length fewer than 2 cm of the stricture, the location in the middle third of the esophagus and the endoscope passage in the first procedure were factors associated with a better prognosis. Airway involvement was also a variable associated with more significant complications. ConclusionsEsophageal dilatations are a fundamental part of the management of strictures. This study found relevant prognostic factors for both the effectiveness of the dilatations and the complications of these. More studies are needed for a gold standard of effectiveness in this condition. Level of evidenceThis is a retrospective study of level III of evidence.

Tear protein analysis in patients with primary acquired nasolacrimal duct obstruction treated with lacrimal passage intubation.

The pathophysiology of nasolacrimal duct obstruction (NLDO) may involve quantitative as well as qualitative changes in tears. We measured tear protein concentrations in patients with primary acquired NLDO and compared them with the tear proteins in healthy individuals and patients with dry eye disease. Case-control study. Twenty-four patients diagnosed with primary acquired NLDO who underwent endoscopic lacrimal passage intubation were included in the study. Tear fluid was collected with Schirmer's test strips three times: before intubation, after intubation while the nasolacrimal tube was in place, and after extubation. At the same time, 24 age-matched normal controls and 24 patients with dry eye were selected from subjects whose tears were collected during the same study period. We measured the following components of tear fluid: total protein, lactoferrin, albumin, and interleukin 6 (IL-6) levels. Total proteins and albumin levels in tears of the NLDO group were significantly lower than those of the control group (P < 0.001 and P = 0.014, respectively, Mann-Whitney U test). Total proteins, albumin, and lactoferrin levels were significantly increased after extubation of nasolacrimal tube (P < 0.001, P = 0.004, and P = 0.029, respectively, Wilcoxon matched-pairs signed-rank test). There were no statistically significant differences in total protein, albumin, lactoferrin and IL-6 levels between patients with NLDO after lacrimal passage extubation and controls. Our study shows distinct differences in protein composition of tear fluid in NLDO eyes and demonstrates that these can be normalized by nasolacrimal tube placement.

Quantification of gastric sleeve stenosis using endoscopic parameters and image analysis

Sleeve gastrectomy has quickly become the most commonly performed bariatric surgery. In light of its increasing popularity, the prevalence of gastric sleeve stenosis (GSS) continues to rise. Management with serial pneumatic dilation is highly successful but underused because of a lack of quantitative diagnostic criteria. We aimed to develop quantifiable endoscopic criteria to characterize GSS based on the (1) ratio of narrowest to widest gastric lumen diameter, (2) endoscope angulation/trajectory required for passage, and (3) presence of bilious fluid pooling in the proximal sleeve and compare it with endoluminal functional lumen imaging probe (EndoFLIP) diameter and distensibility indices (DIs) and endoscopic documentation of gastric lumen morphology. We retrospectively reviewed a prospectively maintained database of patients undergoing endoscopy to assess for GSS. Endoscopic images were reviewed in a blinded fashion by 2 bariatric endoscopists. The narrowest and widest part of the gastric lumen diameters were noted on each image, in addition to a hypothetical trajectory required for endoscope passage. Using image processing software, we calculated the the ratio of diameters (ie, narrowest divided by widest) and angle of endoscope trajectory. The presence of bilious fluid pooling in the proximal gastric lumen was noted. These values were then compared with EndoFLIP parameters and endoscopic documentation of gastric lumen morphology. Thirty patients met inclusion criteria, and 26 (87%) were found to have a stenosis on endoscopy. Of those, 9 (35%) were characterized as mild, 11 (42%) as moderate, and 6 (23%) as severe. There was no difference in demographic information between patients with and without stenosis. In patients with stenosis, mean EndoFLIP diameters and DIs were 12.9 ± 3.9mm and 11.0 ± 6.8mm2/mm Hg, respectively. In patients without stenosis, mean EndoFLIP diameters and DIs were 19.9 ± 2.9mm and 21.5 ± 1.0mm2/mm Hg, respectively. Patients with stenosis had significantly lower diameter ratios compared with those without stenosis (.27 ± .14 vs .48 ± .77, P= .01). Diameter ratios were also inversely related to severity of sleeve stenosis (β= -.08, P= .01). Patients with stenosis were also more likely to have fluid pooling (96.2% vs 25%, P< .001). There was no significant difference in the trajectory of endoscope passage between the 2 groups. Endoscopic criteria for diagnosis of GSS are lacking. Our data suggest the ratio between the narrowest and widest gastric lumen diameters and presence of pooled fluid is associated with diagnosis of stenosis by EndoFLIP and gastric lumen morphology. Future studies to validate these criteria are needed.

Gastrointestinal: Franseen-tip transmural fine-needle biopsy for localized gastric linitis plastica.

A 59-year-old male patient presented with refractory nausea and vomiting. Esophagogastroduodenoscopy revealed a concentric, malignant-appearing stricture in the distal antrum (Fig. 1a). Of note, despite the clinical picture of functional outlet obstruction, endoscopic passage into the duodenum was maintained. However, two extensive rounds of conventional mucosal biopsies (each > 12) did not yield a malignant histology. While a thoracoabdominal computed tomography scan excluded distant metastases, endoscopic ultrasound (EUS) revealed marked, diffusely hypoechogenic wall thickening up to 30 mm with irregular margins and fusion of layers, highly suggestive of gastric linitis plastica (GLP) (Fig. 1b, linear probe: Pentax, EG38J10UT). Final locoregional staging was determined uT3N0, and transmural EUS fine-needle biopsy (FNB) using a novel FNB-dedicated 22G Franseen-tip needle was performed (Acquire, Boston Scientific) (Fig. 1c). Relative to more established EUS-FNB needle, such as the Procore needle, the specific design of the needle with its stabilizing three-point tip allows for improved tissue capture and reduced fragmentation. EUS-FNB was performed in the slow pull technique with extensive fanning through the lesion, resulting in a macroscopically excellent yield (Fig. 1d). Pathology assessment indicated atypical epithelial cells with a prominent desmoplastic stroma within the muscularis propria (Fig. 1e, top). There was faint granular positivity in the periodic acid-Schiff staining, albeit a clear-cut signet ring morphology was absent. Ancillary immunohistochemistries were positive for CK-20 (Fig. 1e, lower left), CDX-2 (Fig. 1e, lower right), and (not shown) carcinoembryonic antigen, while p53 remained negative. In conjunction with clinical characteristics, a final diagnosis of poorly differentiated adenocarcinoma underlying linitis plastica was entertained. After an unremarkable ileocolonoscopy, the patient underwent diagnostic laparoscopy, excluding peritoneal carcinomatosis and providing an enteral nutrition access, and perioperative chemotherapy using FLOT4 (fluorouracil plus leucovorin, oxaliplatin, and docetaxel) was recommended prior to surgical gastrectomy. EUS-based tissue acquisition of either the gastric wall and/or suspicious lymph nodes is instrumental in confirming the malignant nature of gastric wall thickening, albeit the distinct benefit of newer FNB-dedicated needles, such as with a Franseen-tip design, considered to translate into improved maintenance of tissue architecture, is yet to be better determined in systematic, GLP-exclusive analyses.

Obstructive colon cancers at endoscopy are associated with advanced tumor stage and poor patient outcome. A retrospective study on 398 patients.

The detection of obstructive colorectal cancer (CRC) masses during endoscopic examination hindering the passage of endoscope and precluding complete examination is not uncommon. The significance and implications of this finding on patients' prognosis and outcomes were not fully investigated and will be addressed in this study. In this retrospective cohort study, we reviewed endoscopy, surgery, pathology and oncology reports of patients diagnosed with CRC over a 10-year period (2007-2016). We compared surgical stages, histologic grades and overall survival between patients with subclinical obstructive tumors at endoscopy to those with nonobstructive tumors. We performed multivariate analysis to identify independent risk factors associated with advanced CRC stage at diagnosis. A total of 144 patients had obstructive colonic tumors while 254 had nonobstructive tumors and constituted the control group. Obstructive CRC group was significantly associated with advanced tumor stage at diagnosis (69 vs. 42%, OR = 3.018, 95% CI, 1.951-4.670; P < 0.01) and had prominently higher rates of moderate to poorly differentiated tumors (64.5 vs. 38.4%; P < 0.001) when compared to non-obstructive controls. Patients with obstructive tumors were significantly associated with decreased five years overall survival (53.4 vs. 67.3% vs.; P < 0.01). Increased overall mortality was observed in survival curves of patients with obstructive tumors along all follow-up periods. Even in the absence of clinical sequela, obstructive CRC at endoscopic level may be associated with higher stage at diagnosis and reduced overall survival. Further prospective studies are warranted to confirm these findings and address their implication on patients' management.

Mo1706 OBSTRUCTIVE COLON CANCER AT ENDOSCOPY AS AN INDEPENDENT RISK PREDICTOR OF ADVANCED TUMOR STAGE AND REDUCED SURVIVAL

It is still debatable whether a colorectal cancer tumor size affects patients' prognosis and outcome. A more clinically relevant and frequently encountered scenario is the presence of subclinical obstructive mass during endoscopic exam hindering the passage of endoscope and precluding complete exam. The significance and implications of this finding were not fully investigated, and will be addressed in this study. In this retrospective cohort study we reviewed endoscopy, surgery, pathology and oncology reports of patients diagnosed with colorectal cancer over a 10-year period (2007-2016). Data on patients' demographics and ethnicities were documented. Patients with a finding of obstructive tumors at endoscopy were compared to a control group of patients with non-obstructive tumors. We compared surgical stages, histologic grades and overall survival between both groups. We performed multivariate analysis to identify independent risk factors associated with advanced CRC stage and grade at diagnosis. 144 patients had obstructive colonic tumors while 254 had non-obstructive tumors and constituted the control group. Obstructive colon cancer group was significantly associated with advanced tumor stage (Stage 3 or above) at diagnosis compared to the non-obstructive controls (69% Vs. 42%, P<0.01) (Table 1). Likewise, in terms of histologic grade, more patients in the obstructive group were classified as moderate to poorly differentiated compared to controls (64.5 % vs. 38.4%; P<0.001). In multivariate analysis obstructive tumor finding was associated with increased risk of advanced CRC stage at diagnosis (odds ratio=3.018, p<0.0001 and 95%CI=1.951-4.670). A prominent difference of overall survival curves was also noted as obstructive colon cancer was significantly associated with decreased one (77.8% vs. 86%; P=0.01), three (63.6% vs.77.4%; P<0.01) and five years (53.4% vs. 67.3% vs.; P<0.01) survival (Figure 1). Even in the absence of clinical sequela, obstructive colorectal cancer at endoscopic level may be associated with higher stage at diagnosis and reduced overall survival. Further prospective studies are warranted to confirm these findings and address their implication on patients' management.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

A box-shaped, shielding device for reducing the risk of COVID-19 droplet infection during gastrointestinal endoscopic procedures

Endoscopists and endoscopic assistants are easily exposed to germs, including COVID-19, during aerosol-generating procedures such as gastrointestinal endoscopy. This retrospective study investigated the utility of a box-shaped shielding device for reducing the risk of COVID-19 droplet infection during endoscopic procedures. We created a cuboid box (500 × 650 × 450 mm) with four sides were covered with a transparent, vinyl-chloride sheet having two windows for endoscopic passage and assistance. The shielding box was then placed over a patient's head and shoulders and covered with another transparent vinyl sheet. We assessed its utility and safety using the medical data concerning the procedure time and vital signs and a questionnaire for the endoscopic staff and patients. We performed endoscopic retrograde cholangiopancreatography-related procedures using this device for two patients suspected of having COVID-19-associated pneumonia. Both patients were smoothly and successfully treated without any complications. No difficulties were noted with either endoscopic operation or in assisting the procedure, and the transparency was good enough to observe the patients' faces and movements. This box-shaped shielding device can be used to reduce the risk of COVID-19 droplet infection during endoscopic procedures in the clinical setting. The COVID-19 outbreak has reminded healthcare personnel working in endoscopy units of the importance of infection prevention during endoscopy. The box-shaped shielding device can help endoscopic staff avoid hospital-setting COVID-19 infection.

Nasal patency as a factor for successful transnasal endoscopy.

ABSTRACTIn recent years, transnasal endoscopy had been more widely accepted for its safety and convenience, and although it can lead to a weaker pharyngeal reflex, compared with the effects of transoral endoscopy, examinees often suffer intolerable pain and discomfort during passage of the endoscope through the nasal cavity. The aim of this study was to estimate the relationship between the uncomfortable factors during transnasal endoscopy and nasal patency. The subjects comprised 23 consecutive patients who underwent transnasal endoscopy from October 2007 to April 2009 at our Gastroenterology and Otorhinolaryngology Departments. Immediately prior to endoscopy, the left and right nasal resistance was measured with an active anterior rhinomanometer; a value of 100 Pa was determined as nasal resistance. The transnasal endoscope was inserted in the subjectively preferred side by the examinee. Thereafter, the subjects were asked to fill in a questionnaire on physical tolerance during the procedure, to quantify the sensations of nasal pain, nausea, and choking on a 10-point visual analogue scale. The mean scores were 3.0 ± 2.7 for nasal pain, 1.7 ± 2.0 for choking, and 1.6 ± 1.9 for nausea. The most intolerable factor among the complaints was pain (45%), which was followed by nausea (18%) and choking (9%). Unilateral nasal resistance was significantly related with nasal pain only (P = 0.0135). In conclusion, the most difficult problem during transnasal endoscopy was pain, which was related to nasal patency. We successfully demonstrated the clinical significance of nasal patency in determining the side of insertion for transnasal endoscopy.

1764 It’s Not Always Reflux: The Role of High-Resolution Manometry in Management of Patients With Sleeve Gastrectomy

INTRODUCTION: We present cases of esophageal motility disorders associated with sleeve gastrectomy and identify the role of high-resolution manometry (HRM) in perioperative diagnosis and management. CASE DESCRIPTION/METHODS: Case 1: A 44-year old female with history of morbid obesity and gastric reflux presented with persistent symptoms of regurgitation, vomiting, and refractory reflux after undergoing a sleeve gastrectomy two years prior. Upper endoscopy showed slight resistance to endoscope passage at the lower esophageal sphincter and HRM evaluation was consistent with Type II achalasia, a finding confirmed by barium esophagram. The patient underwent a Heller myotomy with conversion into gastric bypass. On follow-up, patient noted no further recurrence of her presenting symptoms. Case 2: 52-year old female with multiple comorbidities presented with refractory dysphagia. She had undergone sleeve gastrectomy 5 years prior and subsequently developed worsening postprandial chest pain and solid food dysphagia. Outside work up of her dysphagia including multiple endoscopies and an esophagram were negative. On present evaluation, a 13 mm Barium pill traversed the esophagus without delay, and HRM showed a hypercontractile esophagus with high normal integrated relaxation pressure. The patient was started on antispasmodic therapy with symptom improvement. DISCUSSION: Laparoscopic sleeve gastrectomy is a bariatric surgical procedure for rapid weight loss in those classified as morbidly obese. The procedure leaves patients with a narrow tubular stomach roughly the diameter of the esophagus. Post operatively, patients have been noted to experience dysphagia, odynophagia, and most commonly (19.7% of cases) reflux. In our cases, patients experienced severe esophageal dysmotility which may have been caused by post-operative alterations of gastric anatomy and pressures. The mechanism behind post-operative motility disorders is unclear, and some studies have suggested that the procedure may unmask previously latent or subclinical disorders rather than induce them. We believe that HRM should be used as part of high value care in evaluating gastric sleeve patients with esophageal symptoms, especially before surgical revisions. Braghetto, I., et al. OBES SURG (2010) 20: 357. https://doi-org.elibrary.amc.edu/10.1007/s11695-009-0040-3.

A Case of Systemic Sclerosis Mimicking Achalasia

Systemic sclerosis (SS) may be associated with GERD symptoms and dysphagia related to esophageal dysmotility or a peptic stricture in 50 - 90% of patients. HRM may show esophageal aperistalsis of the smooth muscle with a low LESp. We present 2 cases of SS presenting with HRM findings characteristic of type I Achalasia; onepatient with symptomatic dysphagia and the other patient with symptomatic GERD and endoscopic esophagitis. Both patients have diffuse SS, Raynaud's phenomenon, interstitial lung disease, GERD and positive SS serologies. Case 1 is a 66 year-old female who developed dysphagia 8 years following SS diagnosis. BaS noted esophageal atony, no strictures and a patulous GEJ, with a normal EGD. GERD symptoms improved with PPIs but she developed progressive solid-food dysphagia without weight loss. Re-evaluation 4 years later revealed a normal EGD while HRM showed aperistalsis, normal LESp with a ?IRP mimicking type I achalasia. Timed BaS demonstrated mild mid-esophageal dilation (3 cm), tapering at the distal esophagus with minimal barium retention at 5 minutes (Fig. 1). Repeat EGD for possible pneumatic dilation, demonstrated a mildly patulous LES that was easily distended following air insufflation and no resistance w ith endoscopic passage through the GEJ. Case 2 is a 54 year old patient with an 11 year history of SSc and GERD but no dysphagia with a mildly dilated esophagus with intraluminal debris (Fig. 2). HRM showed aperistalsis, normal LESp, and elevated IRP (Fig 3). Most recent EGD revealed LA Class B esophagitis. Caution should be exercised in making the diagnosis of achalasia in SS patients. Full evaluation must include a timed barium study, and EGD to be certain that one is dealing with GEJ obstruction. Measurement of the LESp and relaxation are dependent upon: (1) the crural diaphragm which does not relax during swallowing, (2) the intrabolus pressure generated by the fluid passing through the GEJ, and (3) the cephalad movement of esophagus related to longitudinal muscle contraction which shortens the esophagus and momentarily pulls the stomach into the GEJ during swallowing. It is possible that in SS with a dilated esophagus and no muscle contraction, the esophagus did not shorten and LES remained stationary at the level of the crural diaphragm. Few cases exists of SS having HRM criteria for achalasia. These 2 cases presents a hypothesis for further research in SS patients having HRM criteria for achalasia.1722_A Figure 1. Mild esophageal dilation with distal esophageal tapering and minimal barium retention in case 11722_B Figure 2. Mild esophageal dilation with intraluminal debris in case 21722_C Figure 3. Representative esophageal topography of elevated IRP in case 2

Endoscopic magnet placement into subadventitial tunnels for augmenting the lower esophageal sphincter using submucosal endoscopy: ex vivo and in vivo study in a porcine model (with video)

Endolumenal therapies serve as a treatment option for GERD. This study aimed to determine if magnets could be placed endoscopically using the adventitial layer to create a subadventitial space near the esophagogastric junction to augment the lower esophageal sphincter using submucosal endoscopy. This study consisted of 2 phases, exvivo and invivo, with domestic pig esophagus. A long submucosal tunnel was made at the mid to lower esophagus. The muscularis propria was incised by a needle-knife within the submucosal tunnel. A subadventitial tunnel was made by biliary balloon catheter blunt dissection, and a magnet was deployed in the subadventitial space. The same maneuver was done within the opposing esophageal wall, with magnet placement in the opposing subadventitial space. Submucosal tunnels and subadventitial tunnels were successful without perforation exvivo in all attempts and in 9 of 10 cases, respectively. Magnets were deployed in the subadventitial space in 7 cases. Magnets connected and separated with atraumatic endoscope passage into the stomach and reconnected when the endoscope was withdrawn under fluoroscopy in 5 of 7 cases (71.4%). Invivo submucosal tunnels and subadventitial tunnels were successful in all 5 cases, and magnet augmentation was functionally active in 4 cases (80%). Subadventitial tunnels were feasible and could represent a new working space for endoscopic treatment. Endoscopic placement of magnets within the subadventitial space may be an attractive alternative endolumenal therapy for GERD.

The anatomy of the pediatric airway: Has our knowledge changed in 120 years? A review of historic and recent investigations of the anatomy of the pediatric larynx.

There is disagreement regarding the anatomy of the pediatric airway, particularly regarding the shape of the cricoid cartilage and the location of the narrowest portion of the larynx. The aim of this review is to clarify the origin and the science behind these differing views. We undertook a review of published literature, University Libraries, and authoritative textbooks with key search words and phrases. In vivo observations suggest that the narrowest portion of the airway is more proximal than the cricoid cartilage. However, in vitro studies of autopsy specimens measured with rods or calipers, confirm that the nondistensible and circular or near circular cricoid outlet is the narrowest level. These anatomic studies confirmed the classic "funnel" shape of the pediatric larynx. In vivo studies are potentially misleading as the aryepiglottic, vestibular, and true vocal folds are in constant motion with respiration. These studies also do not consider the effects of normal sleep, inhalation agents, and comorbidities such as adenoid or tonsil hypertrophy that cause some degree of pharyngeal collapse and alter the normal movement of the laryngeal tissues. Thus, the radiologic studies suggesting that the narrowest portion of the airway is not the cricoid cartilage may be the result of an artifact depending upon which phase of respiration was imaged. In vivo studies do not take into account the motion of the highly pliable laryngeal upper airway structures (aryepiglottic, vestibular, and vocal folds). Maximal abduction of these structures with tracheal tubes or bronchoscopes always demonstrates a larger opening of the glottis compared to the outlet of the cricoid ring. Injury to the larynx depends upon ease of tracheal tube or endoscope passage past the cricoid cartilage and not passage through the readily distensible more proximal structures. The infant larynx is funnel shaped with the narrowest portion the circular or near circular cricoid cartilage confirmed by multiple in vitro autopsy specimens carried out over the past century.

Endoscopic Balloon Dilation Size and Avoidance of Surgery in Stricturing Crohn's Disease.

Endoscopic balloon dilation (EBD) is an effective method for treating stricture-related obstruction in Crohn's disease. We aimed to identify factors predictive of successful avoidance of surgery, including endoscopic features, in patients undergoing balloon dilation. We performed a retrospective review of patients with symptomatic Crohn's disease-related intestinal strictures undergoing EBD. Clinical, medication use, laboratory, and dilation data, including the minimum and maximum balloon sizes used, and number of balloons used per endoscopic session were collected. Multivariate analysis by Cox proportional hazard regression was used to model future surgical bowel resection. In a total of 135 subjects undergoing 292 dilations, multivariate modeling demonstrated that failure to achieve a maximum dilation of 14 mm or more increased the risk of surgery (hazard ratio [HR] 2.88, 95% confidence limit [CL], 1.10-7.53). Although there was no difference in the risk of future surgery between maximum EBD sizes of 14 to 15 mm and 16 to 18 mm, those reaching 16 to 18 mm exhibited a longer interval between subsequent dilations (mean 240 ± 136.7 versus 456 ± 357.3 d, respectively, P = 0.023). Endoscope passage at index dilation was not predictive of future surgery (HR 0.63, 95% CL, 0.31-1.26). Adjusting for covariates of EBD size, stricture location and type, a C-reactive protein >1.5 mg/dL (HR 2.60, 95% CL, 1.12-5.94), and anti-tumor necrosis factor initiation after index EBD (HR 2.39, 95% CL, 1.09-5.25) increased the risk of future surgery. Although dilation calibers larger than 14 to 15 mm were not more protective against future surgery, those reaching 16 to 18 mm underwent maintenance dilation less frequently. The risk of surgery associated with post-EBD anti-tumor necrosis factor initiation suggests that effective therapy is often used too late in the disease course.

Esophageal triamcinolone acetonide–filling method: a novel procedure to prevent stenosis after extensive esophageal endoscopic submucosal dissection (with videos)

Endoscopic submucosal dissection (ESD) for extensive esophageal carcinomas may cause severe stenosis requiring endoscopic balloon dilations (EBDs). A standard prevention method has not been established. We propose the esophageal triamcinolone acetonide (TA)-filling method as a novel local steroid administration procedure. We enrolled 22 consecutive patients with early esophageal cancer who were treated using either subcircumferential or circumferential ESD (15 and 7 procedures, respectively) in this case series. Esophageal TA filling was performed on the day after ESD and 1 week later and was performed again if mild stenosis was found on follow-up. EBD with TA filling was performed only for severe stenosis that prevented endoscope passage. The primary endpoint was the incidence of severe stenosis. Secondary endpoints were the total number of EBDs and additional TA filling, dysphagia score, time to stenosis and to complete re-epithelialization, and any adverse events. The incidence of severe stenosis was 4.5% (1/22; confidence interval, .1%-22.8%), and EBD was performed 2 times in 1 patient. Mild stenosis was found in 9 patients. Additional TA filling was performed in 45.5% of patients (10/22; median, 5 times; range, 1-13). The dysphagia score deteriorated to 1 to 2 in 31.8% (7/22) but showed a final score of 0 after complete re-epithelialization in 90.9% (20/22). The median time to stenosis was 3 weeks (range, 3-4) and that to complete re-epithelialization was 7 weeks (range, 4-36). No severe adverse events occurred. The esophageal TA-filling method is highly effective for preventing severe stenosis after extensive esophageal ESD.

Risk factor analyses of severe cicatricial stricture after chemoradiotherapy for stage II/III (T3) esophageal carcinoma.

190 Background: Severe benign cicatricial stricture (SBCS) is a major complication after chemoradiotherapy (CRT) for esophageal carcinoma (EC), and causes oral intake impairment leading to deterioration of quality of life even after being cured. Aim of this study was to investigate risk factors of SBCS. Methods: The subjects of this study were patients with stage II/III (T3) EC who received CRT and achieved complete response (CR) between 2000 and 2011. SBCS was determined as disability of passage by diameter-9mm endoscope. Results: Among 197 patients with Stage II/III (T3) treated by CRT, CR was obtained in 91 patients, who were included in this analysis. The median age was 63 years. Fifteen patients (16.5%) were female. The median follow-up time was 5.1 years. The cumulative incidence of SBCS was 15.0% (95%CI 9.0-24.5). Significant risk factors of SBCS were female (hazard ratio (HR) 3.3 (95%CI 1.1-10.0), p = 0.04), requirement of diced/liquid meal (HR 5.7 (95%CI 1.8-18.2), p = 0.003), tumor occupying 3/4 or grater of esophageal perimeter (HR 7.4 (95%CI 1.3-42.9), p = 0.03) and disability of endoscope passage (HR 12.7 (95%CI 4.2-38.5), p &lt; 0.001) in univariate analysis. Hypoalbuminemia increased the risk of SBCS (HR 2.4 (95%CI 0.8-7.1), p = 0.12) marginally. As for the factors during CRT, grade 2-4 esophagitis significantly increased the risk of SBCS (HR 6.2 (95%CI 1.5-25.7), p = 0.01). Multivariate analysis showed that hypoalbuminemia (HR 3.5 (95%CI 1.1-11.1), p = 0.03) and disability of endoscope passage (HR 14.8 (95%CI 4.3-51.3), p &lt; 0.001) were the significant risk factors of SBCS. Female (HR 1.5 (95%CI 0.5-4.9), p = 0.51) was not a significant risk factor in multivariate analysis. Conclusions: Obstructions before CRT, hypoalbuminemia and severe esophagitis during CRT are considered as risk factors of SBCS. Because SBCS occurred after completion of CRT, prophylactic treatment should be established especially for esophageal carcinoma patients with risk factors of SBCS.

Pseudocyst Resolution in Two Shakes of a LAMS Tail

Pancreatic pseudocysts (PPs) develop in approximately 10%-26% of acute pancreatitis cases and 20%-40% of chronic pancreatitis cases. Endoscopic ultrasound-guided cystogastrostomy is the preferred approach to drain pseudocysts. In 2013, the Food and Drug Administration approved a new, lumen-apposing, fully-covered, selfexpanding metal stent (LAMS) which has been used successfully in transmural PP drainage (AXIOS; Xlumena, Mountain View, CA). The LAMS has lumen-apposing ability and a wide diameter allowing for robust drainage and endoscope passage. A recent multi-center retrospective study showed high rates of success in LAMS placement and subsequent resolution of PPs with low major complication rates. The current literature has only discussed high technical success rates utilizing the LAMS in patients presenting with a single PP. We describe a patient who required placement of two LAMSs for drainage of two separate PPs simultaneously. A 71-year-old male with history of recent cholecystectomy presented with sharp, stabbing back and epigastric pain with nausea and vomiting. His lipase was greater than 6000 U/L with elevated liver enzymes and leukocytosis. Abdominal CT revealed acute interstitial pancreatitis, and the patient was subsequently diagnosed and treated for necrotizing pancreatitis. Four weeks later, the patient presented with severe abdominal pain, and a CT showed a 7.2 x 12.5 cm PP closely abutting the lesser curvature of the stomach. Cystogastrostomy was performed and a 15 x 10 mm AXIOS LAMS was placed [Figure 1, 2]. 5 days later, the patient experienced another episode of abdominal pain, and another CT showed resolution of the stented PP as well as a new 5.9 x 6.0-cm x 11.9-cm PP along the lateral margin of the stomach. Cystogastrostomy was again performed and a second 15 x 10 mm LAMS was placed through the second PP while leaving the first LAMS in place [Figure 3]. Repeat CT one month later demonstrated resolution of both PPs. Both stents were removed without complication using a standard snare. Placement of the two LAMSs was well-tolerated by the patient and resulted in the complete resolution of his two PPs. LAMS have been highly successful in treating single pancreatic pseudocysts. Multiple PPs, however, have been reported to occur in up to 18.5% of patients presenting with PPs and can be difficult to treat. Additional research in simultaneous placement of multiple AXIOS LAMSs to treat multiple PPs is warranted.Figure 1Figure 2Figure 3

A Rare Duodenal Mass, Brunneroma: Case Report

A 65 years old female patient referred to our clinic was diagnosed with ileus following laparoscopic cholecystectomy. Contrast-enhanced abdominal tomography (CT) had earlier been applied to determine the underlying cause of ileus. A hypodense 52 × 32 mm sized mass was incidentally detected in the first and second sections of duodenum. In upper gastric endoscopy, submucosal located mass was observed in the first section of the duodenum at the posterior wall, which was not blocking the passage of endoscope. Positron emission tomography (PET) CT examination with a standardized uptake value (SUVmax) of 6 showed a potential malignancy. As the patient’s clinical condition worsened, exploratory surgery was planned. Small bowel adhesions and strangulation were detected. Transduodenal biopsy was taken. Pathological examination revealed hyperplastic Brunner’s glands, which was considered to be Brunner’s Gland Adenoma. Patient was discharged at postoperative day 12 with cure. For diagnosis of BGA, endoscopic ultrasonography and contrasted tomography can be used. In symptomatic cases, transduodenal resection can be performed. In the case of non-symptomatic and incidentally detected duodenal masses, however, PET-CT would be useful. A SUVmax lower than 2.3 suggests a benign mass and a higher value over 5 in PET-CT have a high risk of malignancy. As in this case, gastrointestinal system tumors with a SUVmax greater than 5 is not always related with malignancy. In conclusion, for regular bordered mass images, which are detected at this localization, BGA should be kept in mind for differential diagnosis. Patients with BGA should be followed-up for malignancy and recurrence.

Anterior meatuscopy is more reliable than a sniff test for predicting nasal patency before transnasal endoscopy.

Background and study aims: Unsedated transnasal esophago-gastro-duodenoscopy (UT-EGD) has been performed for at least two decades but many techniques related to the procedure have yet to be standardized. We aimed to develope a simple endoscopic method, anterior meatuscopy, to replace the sniff test for selecting the most patent nasal meatus before UT-EGD. We hypothesized that access to the common nasal meatus (CNM), if confirmed by anterior meatuscopy, was a safer route than the inferior (INM) and middle nasal meatuses (MNM) because it would result in reduced epistaxis, nasal pain, and nasal discharge. Patients and methods: We used anterior meatuscopy and an endoscopic meatus scoring scale (EMSS) to identify the optimal meatus for insertion. We evaluated the EMSS frequency distributions for the INM, CNM, and MNM and the reliability of a sniff test in 1,000 consecutive patients. The adverse effects of passing through the CNM versus the INM and MNM, respectively, were compared. Results: In the INM and MNM, the EMSS frequencies were grade I > II > III > 0 whereas those in the CNM were grade II > I > 0 > III. A sniff test was not reliable, given its low sensitivity (63.3 %), specificity (67.3 %), positive predictive value (69.1 %), negative predictive value (61.4 %), and accuracy (65.2 %). Although only 9.2 % of our patients had grade III anterior-to-posterior CNMs, passage through this spacious CNM rather than through the MNM or the INM could significantly reduce epistaxis, nasal pain, and nasal discharge. Conclusions: Anterior meatuscopy is more reliable than a sniff test before UT-EGD. Transnasal endoscopic passage through the endoscopically patent CNM, if detected by anterior meatuscopy, may prevent epistaxis and nasal pain and minimize nasal discharge.