Faculty Bibliography

Biliary endoprostheses continue to demonstrate their utility and simplicity in daily therapeutic endoscopy. However, the transient nature of these foreign bodies also underscores their potential detrimental effects even after successful deployment. Stent related factors, such as type, length and caliber offer potential avenues to minimize the risk of migration. However, a patient related factor such as the presence of prior abdominal surgeries makes it paramount for endoscopists to ascertain the location of a migrated stent. There is a ripe niche for continued research and development in biodegradable stents.

BACKGROUND/AIMS: Atpresent there are no guidelines for colonoscopy surveillance interval in subjects with unsatisfactory bowel preparation. Study was designed to compare outcomes of repeat colonoscopy at different surveillance intervals in patients with unsatisfactory preparation on index exam. METHODS: Ten thousand nine hundred and eight colonoscopies were done during the study period. Patients with index colonoscopy exam complete up to cecum but suboptimal bowel prep were included. RESULTS: Two hundred and ninety-seven patients met the inclusion criteria. The interval for repeat colonoscopy was <1 year in 38.5%, 1-2 years in 33.3%, 2-3 years in 16.7%, and 3-5 years in 11.5% subjects. Adenoma detection rate (ADR) was 24%, high-risk adenoma detection rate (HR-ADR) was 8.4%, and colorectal cancer detection rate was 1.7%. The HR-ADR based on surveillance intervals <1 year, 1-2 years, 2-3 years, and 3-5 years was 8%, 7.9%, 2%, and 19.4%, respectively. The HR-ADR was significantly higher at surveillance interval 3-5 years (p < 0.05). CONCLUSION: Colonoscopies repeated at interval >3 years showed a significant HR-ADR. The study indicates that a surveillance interval of 3 years can be reasonable for subjects having an index colonoscopy with suboptimal/fair/poor bowel prep and complete colon examination. Colonoscopy should be repeated earlier if symptoms develop.

Background. Utilization of colonoscopy for routine colorectal cancer (CRC) screening in the elderly (patients over 75) is controversial. This study was designed to evaluate if using fecal occult blood test (FOBT) to select patients for colonoscopy can improve yield and be a cost- effective approach for the elderly. Methods. Records of 10,908 subjects who had colonoscopy during the study period were reviewed. 1496 (13.7%) were >/=75 years. In 118 of these subjects, a colonoscopy was performed to evaluate a positive FOBT. Outcomes were compared between +FOBT group (F-Group) and the asymptomatic screening group (AS-Group). The cost-effectiveness was also calculated using a median estimated standardized worldwide colonoscopy and FOBT cost (rounded to closest whole numbers) of 1000 US $ and 10 US $, respectively. Results. 118/1496 (7.9%) colonoscopies were performed for evaluation of +FOBT. 464/1496 (31%) colonoscopies were performed in AS-Group. In F-Group, high risk adenoma detection rate (HR-ADR) was 15.2%, and 11.9% had 1-2 tubular adenomas. In comparison, the control AS-Group had HR-ADR of 19.2% and 17.7% had 1-2 tubular adenomas. In the FOBT+ group, CRC was detected in 5.1% which was significantly higher than the AS-Group in which CRC was detected in 1.7% (P = 0.03). On cost-effectiveness analysis, cost per CRC detected was significantly lower, that is, 19,666 US $ in F-Group in comparison to AS-Group 58,000 US $ (P < 0.05). There were no significant differences in other parameters among groups. Conclusion. Prescreening with FOBT to select elderly for colonoscopy seems to improve the yield and can be a cost-effective CRC screening approach in this subset. The benefit in the risk benefit analysis of screening the elderly appears improved by prescreening with an inexpensive tool.

BACKGROUND: Advances in endoscopic and surgical techniques have increased the frequency and complexity of these procedures, and thus, the incidence of associated complications. AIMS: To describe the use and clinical applications of the Over the Scope Clip (OTSC) system. METHODS: An English language literature search was conducted using the key words "endoscopy" and "over the scope clip" in order to identify human studies evaluating the application of OTSC from January 2001 to August 2012. The indication, efficacy, complications, and limitations were recorded. RESULTS: Overall success rates of OTSC based on current literature range are in the range of 75% to 100% for closure of iatrogenic gastrointestinal perforations, 38% to 100% for closure of gastrointestinal fistulas, 50% to 100% for anastomotic leaks, and 71% to 100% for bleeding lesions. OTSCs have shown 100% success rates in managing postbariatric surgery weight gain secondary to dilation of the gastrojejunal pouch. CONCLUSION: OTSC is easy to use with good results, thus decreasing the morbidity and mortality associated with the complications secondary to both diagnostic and therapeutic endoscopy and avoiding surgery in many situations.

Splenic injury is an uncommon complication of colonoscopy. Less than 100 cases are reported in the English language literature. The exact mechanism of injury to the spleen during colonoscopy is unknown; various authors propose several risk factors and possible mechanisms. Splenic injury can be graded or classified according to the extent of laceration and the severity of the resultant hematoma. The management options range from observation to emergency splenectomy. Computed tomography scan is the most important imaging modality to diagnose splenic injury. Early recognition and appropriate management is of paramount importance in the management of this condition. A high index of suspicion in a patient with persistent abdominal pain after colonoscopy is key especially when a perforated viscous is ruled out. This article outlines the clinical presentation of splenic injury after colonoscopy and delineates a management algorithm.

A case of a biliopleural fistula with a biloma occurring after superselective hepatic transarterial chemoembolization ablation of a metastatic hepatic carcinoid is described. The presentation was complicated by choledocholithiasis. The biloma was successfully treated with endoscopic drainage.

BACKGROUND: Development of persistent gastrocutaneous fistula and leakage after the removal of a PEG tube is a well-known complication. Various treatments including medications to alter gastric pH, prokinetic agents, endoscopic clipping/suturing, electric and chemical cauterization, argon plasma coagulation, and fibrin sealant, have been used with variable success. Although surgical closure is the current treatment of choice, most of the elderly patients are poor surgical candidates because of multiple comorbid conditions. OBJECTIVE: We describe a method of endoscopic suturing of a gastrocutaneous fistula that is a safe and cost-effective alternative to surgical closure. DESIGN: Individual case. SETTING: Community hospital. PATIENT: One elderly patient. INTERVENTIONS: By using a trocar, we placed multiple, long monofilament sutures from the skin around the gastrocutaneous fistula in criss-cross fashion. Gastric ends of these sutures were pulled from the stomach with a snare under endoscopic visualization. Suture knots were made at the gastric end of the sutures and then were pulled back from the cutaneous side. Multiple biopsy specimens were obtained from both ends of the fistula to promote granulation tissue. Final knots were made at skin level to obliterate the fistula. RESULT: Our procedure resulted in complete closure of a large, persistently leaking gastrocutaneous fistula in an elderly patient within 7 days. The patient tolerated the optimal rate of enteral nutrition without further leakage. LIMITATION: Only 1 patient. CONCLUSION: We believe that this method of endoscopic suturing along with de-epithelialization of the fistula tract for persistent gastrocutaneous fistula is a safe and cost-effective alternative to surgical closure.