Skilled Endoscopists Research Articles

Roth Net Assisted Stone Removal via Direct Cholangioscopy

Purpose: Around 90% of extrahepatic bile duct stones are treated with endoscopic sphincterotomy followed by stone extraction, while others require additional intracorporeal lithotripsy for complete stone removal. Direct cholangioscopy (DC) with a mother-baby endoscopic system assists in visualizing and removing difficult to extract common bile duct (CBD) stones, but is limited by inferior optics, narrow maneuverability, and restrictive therapeutic applications from its small working channel. Furthermore, the procedure has poor visibility in dilated ducts, is time consuming, and usually requires the presence of two skilled endoscopists. SpyGlass® cholangioscopy (Boston Scientific) eliminates the need for a second endoscopist but much of the other limitations with the mother-baby endoscopic system remains. A 77 y/o male with a Billroth II for peptic ulcer disease underwent emergent endoscopic retrograde cholangiopancreatography (ERCP) with a limited papillotomy and stent placement for cholangitis. One month later he was re-admitted for elective cholecystectomy and ERCP with CBD stent and stone removal. ERCP with a pediatric colonoscope was initially used to traverse the afferent limb and the previous sphincterotomy was extended via needle knife and dilated up to 18 mm with a 15/16.5/18MM CRETM balloon dilator (Boston Scientific). Multiple balloon sweeps were performed with removal of two stones but a possible third retained stone was seen. The colonoscope was removed and an adult Olympus G-160 gastroscope was successfully passed via afferent limb into the ampulla and CBD where a CBD stone was identified. A Roth net was used to successfully retrieve the stone from the CBD, with DC up to the hilum showing no other additional stones. DC offers direct visualization of the biliary tree for diagnostic and therapeutic interventions, such as treatment of intraductal papillary neoplasm of bile duct, APC of recurrent hepatoma and intraductal growth, and EHL for difficult biliary stones. DC has typically been described using small-caliber endoscopes, with tandem endoscopy in intact gastrointestinal anatomy. Here we present a patient s/p Billroth II who underwent single-step DC with an adult gastroscope, with a novel form of CBD stone retrieval via a Roth net.Figure: [206]Disclosure: Dr. Kim - Consultant: Boston Scientific, Speaker: Gilead.

I-Scan high-definition white light endoscopy and colorectal polyps: prediction of histology, interobserver and intraobserver agreement

Aim of the study was the evaluation of high-definition white light (HDWL) i-Scan endoscopy for diagnostic prediction of histology, inter- and intraobserver agreement for colorectal polyps. In this prospective single-center cohort study, a skilled endoscopist, with HDWL i-Scan, predicted on real-time the histology of 150 polyps from 78 patients undergoing colonoscopy. Subsequently, four endoscopists, not involved in the collection of cases, predicted the polyps' histology (neoplastic vs nonneoplastic) and repeated the assessment after 6 months. Real-time assessment of the lesions predicted a correct histology in 138/150 cases with a sensitivity, specificity, and accuracy of 95, 82, and 92 %, respectively. Sensitivity, specificity, and accuracy of post-acquisition evaluation were 87.7, 61.7, and 82.2 %, respectively. The κ values of inter- and intraobserver agreement of prediction of histology were 0.462 (0.373-0.537) and 0.657 (0.523-0.917). Among the subset of polyps (n = 82) with good/excellent quality image, sensitivity and accuracy of HDWL i-Scan improved (97 %, p = 0.003 and 94 %, p = 0.002, respectively) as well as κ value of interobserver agreement (0.699). HDWL i-Scan technology helps for characterization of polyps of the colon with good accuracy even if it cannot replace, at the moment, the histopathological examination. Reproducibility among operators is supported by a moderate substantial interobserver and intraobserver agreement.

Spiral enteroscopy: Prime time or for the happy few?

Spiral enteroscopy is the newest of the deep enteroscopy techniques. The current technique employs an overtube with a raised spiral at the distal end to pleat the small intestine and achieve deep small bowel intubation. Although spiral enteroscopy is a novel technique, the learning curve is comparable to the balloon enteroscopy techniques. There is some evidence of improved speed of spiral enteroscopy procedures with superior control compared to the balloon endoscopy technologies. Altered surgical anatomy deep enteroscopy has been shown to have similar safety and efficacy to competitive technologies, particularly in cases of Roux-en-Y ERCP cases. Spiral enterosopy is safe and effective for deep small bowel enteroscopy and diagnostic yield and therapeutic yields are similar to alternate technologies. There are bright future applications of the technology with enteroscopes and an integrated spiral. Spiral enteroscopy is an advanced technique that can be performed by any skilled endoscopist.

PWE-178 Feasibility, safety and efficacy of endoscopic resection of upper gastrointestinal submucosal lesions in a western setting

IntroductionSubmucosal lesions are a relatively common finding at upper gastrointestinal endoscopy. Endoscopic resection (ER) may be warranted in larger lesions, those causing symptoms or those with malignant potential. However submucosal...

PWE-024 Prevalence, management and outcome of submucosally invasive cancers in a western oesophagogastric EMR population

IntroductionRisk of lymph node metastases depends on good or bad prognostic features of submucosally (SM) invasive cancer specimen following endoscopic resection (ER). Invasion limited to SM1 level, lack of lymphovascular...

Training of Surgical Endoscopists in Korea: Assessment of the Learning Curve Using a Cumulative Sum Model

Surgeons' interest and participation in endoscopy have increased recently. The aims of the present study were to assess the learning curve for surgical training in upper endoscopy and to suggest an appropriate training program for surgeons in Korea. Under the supervision of skilled endoscopists, 4 trainees who participated in this study performed more than 150 esophagogastroduodenoscopy procedures, according to the recommendations of the American Society for Gastrointestinal Endoscopy. The success of the procedures was defined as the fulfillment of designated time and checkpoints. A cumulative sum model was used to assess the learning curve. During the same period, the 4 trainees completed 158, 160, 166, and 180 procedures, respectively. Plateau points occurred on the learning curve at the 81st, 90th, 98th, and 111th case in the cumulative sum model and the mean value of the plateau was the 95th case. An intensive education tool and training module that meets the conditions of surgical residents is mandatory for the training of proficient surgical endoscopists.

Sa1857 Modeling Endoscopist Technique Using Linear Predictive Coding: Analysis of Colonoscopy Force Application Signals

Colonoscopy requires a skilled endoscopist to use visual and tactile information to advance and withdraw the instrument through a series of fixed and stationary loops. Maneuvering is accomplished by applying a complex set of maneuvers using axial and rotational force to the insertion tube. The Colonoscopy Force Monitor(CFM) is a handheld device that grips the colonoscope insertion tube, measures and records this applied force signal. Linear Predictive Coding(LPC) and Principal Component Analysis(PCA) are mathematical techniques used to characterize complex digital signals. LPC is widely used for speech analysis and synthesis. The goal of these studies was to determine whether advanced signal processing techniques such as LPC and PCA could be used to characterize endoscopist force application patterns. Methods: Twenty-seven endoscopists used the CFM to perform colonoscopy on 62 male and 52 female patients with a mean age 55.2 and 56.1 yrs, respectively. For each colonoscopy axial and longitudinal forces were recorded at a frequency of 30 samples/sec, transmitted wirelessly to a laptop PC and stored. LPC and PCA were applied to the CFM raw force signal to determine whether a unique endoscopist signature could be identified. Results: Eleven axial and longitudinal force parameters and exam time were calculated for each exam and operator. LPC and PCA analysis was applied to each digital force recording. Figure 1 presents the data plotted in the first two principal coordinates from this analysis for 19 exams performed by 4 of 27 operators. This new representation minimizes the covariance among the data elements enabling seperation in a first order manner. Each marker represents a single case and the same marker represents procedures performed by a single operator. Individual cases are distributed widely across the LPC/PCA space, however, cases performed by a single operator cluster in a more limited area. In contrast, there was overlap among operators using force and time parameters. For example, operators 1 and 2 used conscious sedation and had an average peak force and exam time of 26.1N and 18.2 min and 14.5N and 23.4 min, respectively. Operators 3 and 4 used propofol anesthesia but with similar average peak force of 29.2 and 17.6N and shorter exam times of 16.8 min and 9.2 min, respectively. Conclusion: The present study describes the clinical application of advanced digital signal processing algorithms to characterize endoscopist force application behavior. A combination of LPC and PCA provided a unique signature for each colonoscopy and for each endoscopist. The LPC/PCA classification separated endoscopists who did not differ based on measures of force and time. The LPC/PCA methodology could provide an alternative means of identifying endoscopist behavior that could classify endoscopists, patients and outcome characteristics.

Su1117 Prevalence, Management and Outcome of Submucosally Invasive Cancers in a Western Oesophagogastric EMR Population

Introduction Risk of lymph node metastases depends on good or bad prognostic features of submucosally (SM) invasive cancer specimen following endoscopic resection (ER). Invasion limited to SM1 level, lack of lymphovascular invasion and well differentiated grade are good prognostic features and may indicate that radical resection is not required following ER. However, depth of SM invasion can be very difficult to assess in ER specimens and hence a “safe” strategy would be to offer radical surgery to all patients with SM invasive disease, irrespective of other features. This is the policy we follow. We aimed to evaluate the outcome of these cancers in an ER population. Methods All Upper Gastrointestinal ER procedures for the period 2005–2011 were recorded on a prospective database. All procedures were carried out by a single skilled endoscopist. Demographic data, histology, procedure success, long-term outcome and complications were assessed. Careful endoscopic assessment using chromoendoscopy, plus CT/EUS where appropriate, were performed prior to attempted endoscopic resection and afterwards if indicated. Results Cancer with submucosal invasion was detected in 26 of 123 (21.1%) cases of oesophagogastric neoplasia. 22 patients were male and the mean age was 75.2 years (range 54–84 years). Submucosal invasion was present in 16 of 74 (21.6%) lesions arising in Barrett9s oesophagus, 4 of 7 (57.1%) oesophageal squamous lesions and 6 of 39 (15.3%) gastric lesions. All patients were discussed at a multidisciplinary meeting and those patients who were fit were offered radical surgery or chemoradiotherapy. Six patients who were offered radical surgery opted for conservative management with endoscopic follow-up. 14 patients proceeded to radical surgery; six of these had no residual cancer in surgical specimen and eight had residual cancer present. 11 of the 14 are currently in disease free survival, two died of recurrence and one died of post-operative complications. Two patients received radical chemoradiotherapy; one is in disease free survival, the other died of advanced adenocarcinoma. One patient received radical radiotherapy and remains free of recurrence. Nine patients received conservative/endoscopic management; of these seven had disease free survival, two died of metastatic adenocarcinoma. Mean follow-up was 32 months. Conclusion Our results show that submucosal invasion is found in a significant proportion of patients undergoing upper gastrointestinal ER. Management of SM invasive cancer following ER remains challenging and our series shows a wide variation in management outcomes. Further research to guide the optimum management of this group of patients is required. Competing interests None declared.

Tu1733 Feasibility, Safety and Outcome of “Up and Back” Protocol for Advanced Endoscopic Procedures

Timely & successful intervention is critical in complex gastrointestinal conditions to prevent serious morbidity and mortality. Availability of skilled therapeutic endoscopists is variable, especially in smaller communities with limited access to medical resources. The standard pathway of “transfer and admission” (of patients admitted at outlying hospitals) to the tertiary center for specialized endoscopy is fraught with logistical issues (eg. bed availability) and delays care. To circumvent this problem, our center has developed a “same-day referral” pathway for selected outlying inpatients to receive advanced endoscopic services.

Su1306 Safety, Quality and Comfort of Upper Gastrointestinal Endoscopy With Conscious Sedation After Fasting for Two Hours

Su1306 Safety, Quality and Comfort of Upper Gastrointestinal Endoscopy With Conscious Sedation After Fasting for Two Hours

Su1425 Effect of Body Mass Index (BMI) and Procedure Difficulty on Force Applied During Colonoscopy

Colonoscopy requires a skilled endoscopist to advance and withdraw the instrument through a series of fixed and stationary loops. Procedure difficulty may depend on the patient's physical characteristics such as BMI and colonic redundancy. Prior studies of force application indicate that forces vary by endoscopist, anesthesia and gender. The purpose of this analysis was to measure differences in axial and longitudinal force patterns in obese, overweight and normal weight patients as well as those classified as having difficult colonoscopies.

Endoscopic submucosal dissection for superficial esophageal neoplasms

Endoscopic submucosal dissection (ESD) is currently accepted as the major treatment modality for superficial neoplasms in the gastrointestinal tract including the esophagus. An important advantage of ESD is its effectiveness in resecting lesions regardless of their size and severity of fibrosis. Based on excellent outcomes for esophageal neoplasms with a small likelihood of lymph node metastasis, the number of ESD candidates has increased. On the other hand, ESD still requires highly skilled endoscopists due to technical difficulties. To avoid unnecessary complications including perforation and postoperative stricture, the indications for ESD require careful consideration and a full understanding of this modality. This article, in the highlight topic series, provides detailed information on the indication, procedure, outcome, complications and their prevention in ESD of superficial esophageal neoplasms.

Magnetic endoscopic imaging as a guide to smart colonoscopy

The enormous numbers of colonoscopies now performed worldwide make it more important than ever to optimize initial colonoscopy training and to develop a methodology for assessing the objective competence of endoscopists. At the early training stage only completion rate and the time taken to reach the cecum are the available end-points, which provide realistic but clear measures of actual skill, while perforation and potential mortality are cited as significant limitations of colonoscopy. Therefore, in the early days of colonoscopy the procedure was often performed with the use of fluoroscopy to visualize the endoscope.1 Today, fluoroscopy is reserved for exceptional cases due to the added expense, inconvenience and radiation risk it presents, both to the patient and the medical staff. As a consequence generations of endoscopists have remained unaware of the potential advantages that imaging of the endoscope configuration offers when compared to the blind insertion of the endoscope. Loop recognition, management and straightening are all important aspects of quality colonoscopy. Loops are easier to understand and reduced when displayed on a screen, rather than by guessing and by feel alone. While it is a bonus for trainees and certainly for the patient to have the teacher standing alongside, a long apprenticeship phase and the 100–300 subsequent solo procedures needed to achieve supposed competence are also costly for the hospital and the supervising endoscopist (C. Williams 2011, pers. comm.). In 1993 magnetic endoscope imaging (MEI) was first presented as an alternative to fluoroscopy.2 MEI is derived from very low-strength magnetic fields generated by a series of tiny wire coils positioned along the length of the colonoscope. It provides real-time three-dimensional views of the colonoscope shaft configuration and its location within the abdomen on a separate computer monitor. Several studies have shown that MEI reliably permits the exact localization of colonic pathologies.3-5 Thus, it can be used for follow-up examination after local treatment or in patients with small colorectal tumors for whom surgery is planned. Although initial studies suggested that the use of the MEI could also improve the performance of both skilled and trainee endoscopists allowing a higher colonoscopy completion rate,6 only a few further randomized trials have been reported in the literature and showed conflicting results with regard to intubation times and rates as well as the need for sedatives and the pain experienced by the patient.3, 7-9 Moreover, most of these studies did not include enough patients to gain enough statistical power to show the difference between the groups who do and do not use MEI. In this issue of the Journal of Digestive Diseases Dechêne et al. present the largest study evaluating the use of MEI for colonoscopy done to date and add valuable information about the utility of MEI.10 With the inclusion of 1000 patients results are reliable. The authors found that the use of MEI did not accelerate cecal intubation times. However, the duration of abdominal compression was significantly shorter and the intensity of abdominal compression was lower in MEI-guided colonoscopy. Moreover, fewer turn maneuvers per patient were needed in the group with MEI. This depicts what MEI is able to offer for colonoscopy in the era of potent analgosedation. MEI facilitates the technical performance of colonoscopy by showing what is really going on inside the patient. Endoscope looping and the effects of rotation and withdrawal can be directly observed. Further, MEI permits the precise and effective administration of external abdominal compression. On the other hand, cecal intubation rates and times are rather dependent on adequate bowel preparation and the use of sedatives allowing the insertion of the endoscope even in the presence of normally painful stretching of the colon.11 Nevertheless, the personal aim of each endoscopist should be the exertion of the optimal technique, for example, by the use of MEI, thereby keeping the use of sedatives low. Given the obvious advantages of the application of a safe endoscope imaging method the question arises why MEI has not been used in every endoscopy unit so far. Indeed, most endoscopists consider that the benefits of MEI are not big enough to compensate for the additional costs for the special equipment and colonoscopes. Here, the manufacturer would have to concede. For the endoscopist MEI is finally like all the other small things that make life easier: once you have used it, you would not like to not to have it.

EXPERIMENTAL ENDOSCOPIC SUBMUCOSAL DISSECTION TRAINING IN A PORCINE MODEL: LEARNING EXPERIENCE OF SKILLED WESTERN ENDOSCOPISTS

Endoscopic submucosal dissection (ESD) demands a new level of endoscopic skill in Europe. A 2-day workshop was set up for trainees to carry out five ESD each in order to obtain the skill level required to perform ESD in the stomach or rectum. This study describes: (i) the workshop setup; (ii) the participant's performance; and (iii) the training effect on post-workshop clinical ESD performance. Eighteen very experienced European endoscopists participated in four half-day (4.5 h) training sessions, with everybody rotating daily through six separate training stations (two each with dual, hook, or hybrid knives) with expert tutors. One anesthetized piglet was used per station and session. After 1 year, the clinical ESD performance was surveyed to estimate the training effect of the workshop. Overall, 74 ESD were performed, that is, 4.1 ESD per participant. On average ESD lasted 57 min for 6 cm(2) specimens. We detected a 22% rate of perforation (16 of 74 ESD with perforations), mostly attributable to participants with less experience in ESD. Those who started clinical ESD within 1 year after the workshop performed 144 clinical ESD (median 8 [0-20] per trainee) mostly in the stomach (40%) and large bowel (46%) with an acceptable rate of perforation (9.7%) and surgical repair (3.5%) without mortality or persistent morbidity. Intense skill training for ESD is needed to reduce the risk of perforation, as demonstrated by the results of this workshop. We show that experimental ESD training, however, enables skilled European endoscopists to perform ESD in standard locations with moderate risk of perforation during the clinical learning curve.

Upper gastrointestinal EMR service: long-term feasibility, safety, efficacy and cost effectiveness from a large UK centre

<h3>Introduction</h3> Endoscopic resection (ER) is an accepted treatment of early upper gastrointestinal neoplasia in Europe, but surgery remains the gold standard in the UK due to lack of data. We started an upper gastrointestinal ER service in 2005 and are reporting our 6 year outcome data. We serve six different regional cancer centres. <h3>Methods</h3> We analysed our database of all upper gastrointestinal (UGI) endoscopic resection procedures performed at our centre for the period 2005–2010. All procedures were carried out by a single skilled endoscopist. Demographic data, histology, procedure success, long-term outcome and complications were assessed. <h3>Results</h3> We have performed 160 UGI ER procedures (108 oesophageal (O), 29 gastric (G), 33 duodenal/ampullary (D)) in 127 patients (O=75, G=25, D=27). Mean age was 65.9 years (range 25–94). A mean of 1.32 UGI ER procedures were performed per patient (range 1–5). All neoplastic cases were diagnosed as high grade dysplasia or intramucosal cancer prior to EMR. Overall complication rate was 5.0%. Specific complications were four procedural bleeds and two delayed bleeds (all controlled endoscopically) one full thickness perforation clipped endoscopically and one episode of pancreatitis. There were no cases of procedure related mortality. 25 patients (19.7%) were upstaged, having been found to have sm1 invasion or deeper on histological examination of the initial ER specimen. This group were considered for radical treatment if fit, or conservative management if unfit or through patient choice. 16 patients (O=11, G=4, D=1) proceeded to radical surgery, of which 2 patients died of postoperative complications and 2 patients died of local recurrence; the other 12 remain well. 2 patients received chemo/radiotherapy; 1 died of advanced oesophageal cancer, the other remains well. Of the remaining 102 patients complete local remission was achieved in 79.4% of cases following a single ER procedure, and in 97.1% overall. After a mean 2.57 years follow-up; 4% of all patients are known to have recurrence or metachronous disease and are awaiting further ER. Development of our service has potentially led to a cost saving of £91 270 per year, plus 170 bed days saved per year through reduced requirement for radical surgery. <h3>Conclusion</h3> Our data demonstrates the long-term feasibility, efficacy and safety of an innovative ER service. It provides valuable information about the number and type of patients requiring this service helping inform future planning and commissioning. Our data demonstrates significant cost savings for the NHS.

Does Colonoscopy by a Skilled Endoscopist Cause Any Adverse Effects in Quiescent Ulcerative Colitis Patients? A Case-control Study

Does Colonoscopy by a Skilled Endoscopist Cause Any Adverse Effects in Quiescent Ulcerative Colitis Patients? A Case-control Study

Long-term outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms

Endoscopic submucosal dissection (ESD) provides a high en bloc resection rate with less invasiveness than surgical resection for large or scarring gastrointestinal neoplasms. However, detailed outcomes in colorectal ESD are still lacking. The aim of our study was to elucidate short- and long-term outcomes of colorectal ESD. 310 consecutive colorectal epithelial neoplasms (146 adenomas, 164 carcinomas), in 290 patients, which fulfilled our indication criteria and were treated with ESD between July 2000 and December 2008 were studied. ESD was done by three skilled endoscopists. As short-term outcomes, rates of en bloc resection, en bloc plus R0 resection, and major complications were analyzed. As long-term outcomes, disease-free and overall survival were assessed in 224 patients. Rates of en bloc resection and en bloc plus R0 resection were 90.3 % and 74.5 %, respectively. Eight patients underwent additional colectomy due to histopathologically proven possible node-positive cancer. Intraoperative perforations occurred with 14 lesions (4.5 %), which were treated successfully only by endoscopic clipping. Emergent surgery was needed for one case of postoperative perforation. Blood transfusion due to intraoperative massive bleeding was required in 1 case (0.3 %). Postoperative bleeding occurred with four lesions (1.3 %), and was endoscopically managed without blood transfusion. Local recurrence was detected in 4 lesions (4/202 patients, 2.0 %); resection had been piecemeal in all 4. During a median follow-up of 38.7 months (range 12.8 - 104.2), the 3- and 5-year overall/disease-specific survivals were 97.1/100 % and 95.3/100 %, respectively. Colorectal ESD showed favorable long-term outcomes. It may largely replace colectomy for node-negative colorectal epithelial neoplasia.

Acute esophageal variceal bleeding: Current strategies and new perspectives

Management of acute variceal bleeding has greatly improved over recent years. Available data indicates that general management of the bleeding cirrhotic patient by an experienced multidisciplinary team plays a major role in the final outcome of this complication. It is currently recommended to combine pharmacological and endoscopic therapies for the initial treatment of the acute bleeding. Vasoactive drugs (preferable somatostatin or terlipressin) should be started as soon as a variceal bleeding is suspected (ideally during transfer to hospital) and maintained afterwards for 2-5 d. After stabilizing the patient with cautious fluid and blood support, an emergency diagnostic endoscopy should be done and, as soon as a skilled endoscopist is available, an endoscopic variceal treatment (ligation as first choice, sclerotherapy if endoscopic variceal ligation not feasible) should be performed. Antibiotic prophylaxis must be regarded as an integral part of the treatment of acute variceal bleeding and should be started at admission and maintained for at least 7 d. In case of failure to control the acute bleeding, rescue therapies should be immediately started. Shunt therapies (especially transjugular intrahepatic portosystemic shunt) are very effective at controlling treatment failures after an acute variceal bleeding. Therapeutic developments and increasing knowledge in the prognosis of this complication may allow optimization of the management strategy by adapting the different treatments to the expected risk of complications for each patient in the near future. Theoretically, this approach would allow the initiation of early aggressive treatments in high-risk patients and spare low-risk individuals unnecessary procedures. Current research efforts will hopefully clarify this hypothesis and help to further improve the outcomes of the severe complication of cirrhosis.

Endoscopic ultrasound in chronic pancreatitis: Where are we now?

Endoscopic ultrasonography (EUS) is well suited for assessment of the pancreas due to its high resolution and the proximity of the transducer to the pancreas, avoiding air in the gut. Evaluation of chronic pancreatitis (CP) was an early target for EUS, initially just for diagnosis but later for therapeutic purposes. The diagnosis of CP is still accomplished using the standard scoring based on nine criteria, all considered to be of equal value. For diagnosis of any CP, at least three or four criteria must be fulfilled, but for diagnosis of severe CP at least six criteria are necessary. The Rosemont classification, more restrictive, aims to standardize the criteria and assigns different values to different features, but requires further validation. EUS-fine needle aspiration (EUS-FNA) is less advisable for diagnosis of diffuse CP due to its potential side effects. Elastography and contrast-enhanced EUS are orientation in differentiating a focal pancreatic mass in a parenchyma with features of CP, but they cannot replace EUS-FNA. The usefulness of EUS-guided celiac block for painful CP is still being debated with regard to the best technique and the indications. EUS-guided drainage of pseudocysts is preferred in non-bulging pseudocysts or in the presence of portal hypertension. EUS-guided drainage of the main pancreatic duct should be reserved for cases in which endoscopic retrograde cholangiopancreatography has failed owing to difficult cannulation of the papilla or difficult endotherapy. It should be performed only by highly skilled endoscopists, due to the high rate of complications.

Characterization of Colonoscopic Tactile Forces: Quantitative Differentiation of Colonoscopy Technique Among Experienced Endoscopists

Colonoscopy requires a skilled endoscopist to use visual and tactile information to advance and withdraw the instrument through a series of fixed and stationary loops. Development and retention of the skills necessary to perform colonoscopy safely and effectively requires extensive training and ongoing education. Quantification of tactile information provides the opportunity to measure the "feel” used by the endoscopist to perform colonoscopy, identify force application patterns, enhance training and improve performance. The purpose of this study is to evaluate a push-pull force and torque measuring device that grips the colonoscope shaft and wirelessly transmits and records all forces applied by the endoscopist during colonoscopy. Methods: The Colonoscopy Force Monitor™ (CFM) is a novel handheld device that attaches to the colonoscope and measures applied forces. The device enables the endoscopist to maintain a conventional hand position and uses an electronically controlled grip and release mechanism to fix the CFM position on the instrument. Four expert endoscopists performed colonoscopy in 20 patients. There were 13 men and 7 women with a mean age 56.0 ± 11.4 yrs. Results: Mean time to cecum was 10.0 ± 5.0 min, and mean meperidine and midazolam doses were 42.9 ± 11.6 mg and 2.5 ± 0.8 mg, respectively. Pain score assessed by the endoscopist, nurse and patient on a scale of 1-4 (1=none, 4=severe) was 1.4. Median push and pull forces were 16.2 and -18.8N with peak force of 34.0 for push and -37.7N for pull, respectively. Maximum clockwise and counter-clockwise torques were 0.47Nm and -0.42Nm with peak torque force of 0.83 and -0.88Nm, respectively. For each endoscopist and for each case both maximum force and force impulse were calculated and plotted. These calculations and plots were used to evaluate the pattern of force application used by each endoscopist. The mean force impulse pattern was not different between male and female patients. However, there were clear differences in maximum push/pull force and torque and force impulse distribution among endoscopists. Conclusion: The present study describes the clinical application of a novel device for measurement of the applied forces during colonoscopy. The device provides comprehensive quantitiative tactile data about performance. The CFM generated data distinguishes patients and endoscopists and could lead to an improved understanding of colonoscopic technique. Further development and clinical use of the CFM are likely to contribute to improved performance and enhancec education by quantifying the force application techniques.(Grant Support NIH/NIDDK SBIR 5R44DK068936-03)