Table of Contents

Volume 1, Issue 3

  July/August/September 2011

  Pages 95 - 144

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EDITOR'S CORNERS

Open Access Article

Meet the Executive Editor-in-Chief

Zhao-Shen Li
Page 95
Abstract | PDF

Professor Zhao-shen Li is the Director of the Gastroenterology Department of Second Military Medical University in Shanghai, China. His Department is recognized at the National and Local levels for their contributions in the study of pancreatic diseases and endoscopic therapy for GI diseases. The Digestive Endoscopy Department is one of the accredited endoscopy training centers by the Asian Pacific Society of Digestive Endoscopy. Professor Li is a member of the Disciplinary Appraisal Panel under the Academic Degrees Committee of the State Council. He is the also the Chairman of the Chinese Society of Digestive Endoscopy. Prof. Li graduated from the Second Military Medical University with a degree in clinical medicine in 1980. He was the first visiting scholar from China to undergo advanced endoscopy training at the Prince of Wales Hospital, the Chinese University of Hong Kong in 1994. He has contributed many creative studies in clinical application of endoscopic technology in the management of pancreatic diseases and Helicobacter pylori-related GI problems. He is the Editor-in-Chief of the Journal of Interventional Gastroenterology, Chinese Journal of Digestive Endoscopy and Chinese Journal of Pancreatology. He is an editorial board member of Alimentary Pharmacology & Therapeutics, Hepatobiliary Pancreatic Diseases International, World Journal of Gastroenterology, and Journal of Digestive Diseases. Prof. Li was the president of the Global Chinese Conference on Gastrointestinal Endoscopy in 2005 and 2009. He chaired the 10th International Workshop & Symposium on Therapeutic Endoscopy & Gastroenterology and the World EUS Congress in 2010. He has published 13 monographs including Endoscopy in Diagnosis and Treatment of Gastroenterology Disease, Pharmacotherapeutics for Modern Digestive Disease, Endoscopic Ultrasonography, Modern Pancreatology, Endoscopy in Biliary Disease, and Endoscopy in Pancreatology. He has published 116 peer reviewed papers including many in Gut, Hepatology, American Journal of Gastroenterology, Gastrointestinal Endoscopy, and Endoscopy. His significant contributions included management of foreign bodies in the upper GI tract, multicenter controlled studies to prevent post-ERCP pancreatitis, and he is credited for his efforts in endoscopy training using hands-on practice courses for ERCP in China. In addition to the many endoscopic accessories and equipment he designed, Prof. Li developed a special biliary stent for use with radioactive implants for the treatment of malignant pancreaticobiliary obstruction. This invention won the gold prize in Chinese Patent Technology Exposition. He has made significant contribution in the use of EUS and FNA in the early diagnosis of pancreatic cancer and developed a new technique of EUS-guided interstitial implantation of 125iodine seeds for treatment of patients with advanced pancreatic carcinoma. Prof. Li is also actively involved with establishing guidelines and quality control standards for digestive endoscopy practice in China.

Open Access Article

Introduction to the third issue

Felix W. Leung and Joseph W. Leung
Page 96
Abstract | PDF

Welcome to the third issue of the Journal of Interventional Gastroenterology. In this issue, it is exciting to see the work related to the teaching, learning and outcome of water method for colonoscopy unfolding. This is particularly germane to the discussion of present-day colonoscopy training and improving the quality of colorectal cancer screening by optical colonoscopy. We learn from all our professional society guidelines and recommendations authored by leading experts that perhaps colonoscopy training in the past was suboptimal in many training programs. Experts are needed to point out that quality colonoscopy involves comprehensive documentation: pre-procedure risk assessment; depth of insertion of the colonoscope; quality of the bowel preparation; complete description of the polyps found, including the location of each polyp, size, number and gross morphology; and recommendations for follow up. Much less has been said about the actual methodological improvement needed to enhance the quality of the actual performance of colonoscopy. The reports on the water method have highlighted the difference between conventional air insufflation and the innovative water method – not merely as a convenient air-water hybrid, or the literal interpretation of water replacing air to distend the colon as in water immersion. Air insufflation could lengthen the colon and exaggerate angulations at the flexures making colonoscopy difficult. This was why significant emphasis was placed on minimal air insufflation in the past by leading experts. On the other hand, water exchange is an essential part of the water infusion in lieu of air insufflation method which facilitates local viewing with minimal distension to aid scope insertion. Once understood, the water method is easy, simple and inexpensive. However, it does require active learning by novice (or re-learning by experienced colonoscopist) and repeat practice to master the essential skills. Coaching provided by an experienced endoscopist during initial clinical performance may help to shorten the learning process. A number of published randomized controlled studies comparing the water immersion method with usual air insufflation indicated a significant reduction of pain and sedation medication used and an increase in the proportion of patients completing unsedated colonoscopy. The significant difference is even more dramatic when water exchange was employed. There are also data to indicate that water exchange is crucial to the benefits of the water method in improving adenoma detection rate which could be variable or even significantly decreased by water immersion. Whether the water method alters the outcome of colorectal cancer screening (particularly in the right colon) will have to await longer term studies. It behooves the colonoscopy community worldwide to support evaluation of this important clinical research question, especially if there are concerns that optical colonoscopy could lose ground to other novel technologies. The Journal has started a new section on rapid communication which allows investigators to report their findings on novel ideas or techniques that hold promise of impact on clinical management as well as opening up new avenues for investigations.




ORIGINAL PAPERS

Open Access Article

The water method for aiding colonoscope insertion: The learning curve of an experienced colonoscopist

Francisco C. Ramirez and Felix W. Leung
Pages 97 - 101
Abstract | PDF

Background: The water method has promising features for colonoscopy but the learning curve to master the technique is unknown. Aims: To describe the learning phase, and pitfalls of the water method and its impact on procedural outcomes by anexperienced colonoscopist. Design: Review of prospectively collected data in a performance improvement project Setting: Endoscopy Unit at a VA medical center Patients: 200 consecutive veterans undergoing colonoscopy Methods: An experienced colonoscopist examined 4 consecutive groups of 25 patients each using the water method todene the learning curve. Outcomes were compared to a historical cohort (n=100) examined by the same colonoscopist using usual air insuation. Main outcome measures: Intent-to-treat (ITT) cecal intubation rate. Results: ITT cecal intubation rate increased from 76% (rst) to 96% (fourth quartile). Cecal intubation time in the rst 2 quartiles was signicantly longer (8.9±1.0 and 8.2±0.8 min, respectively) than that in the historical cohort (5.8±0.4 min)but decreased and became comparable to control values in the next 2 quartiles (7.2±0.9 and 6.6±0.6 min, respectively). Overall adenoma detection rate as a group (55%), compared favorably to the historical cohort (46%). Conclusions: The water method is relatively easy to learn for an experienced colonoscopist. Mastery of the method resulted in cecal intubation rate and overall adenoma detection rate meeting quality erformance standards.

Open Access Article

Comparison of diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration with 22- and 25-gauge needles in the same patients

Mitsuhiro Kida , Masao Araki, Shiro Miyazawa, Hiroko Ikeda, Miyoko Takezawa, Hidehiko Kikuchi, Maya Watanabe, Hiroshi Imaizumi and Wasaburo Koizumi
Pages 102 - 107
Abstract | PDF

Background: Various factors, such as the optimal number of passes, aspiration pressure, and the use of 19-gauge and Trucut biopsy needles, have been studied to improve the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). We retrospectively compared the diagnostic accuracy of EUS-FNA between 25- and 22-gauge needles, which have been widely used recently. Subjects and Methods: The study group comprised 47 consecutive patients who underwent eUS-FNA with both 22- and 25-gauge needles from October 2007 through March 2010. Their underlying diseases were pancreatic cancer in 24 patients, submucosal tumors in 11, other pancreatic tumors in 4, chronic pancreatitis in 4, enlarged lymph nodes in 3, and gall bladder cancer in 1. Tissue specimens, which were pushed out of the puncture needle, were placed into physiological saline solution. Gray-whitish, worm-like specimens were used for histologic diagnosis. The remaining specimen was centrifuged, and the sediment was plated on slides and examined by a cytopathologist to obtain the cytologic diagnosis. Results: A total of 75 punctures (mean, 1.6) were performed with 25-gauge needles, and 69 punctures (mean, 1.4) were performed with 22-gauge needles. The overall tissue-sampling rate for cytology was 100% (47/47), which was significantly (p=0.01) superior to 83% (39/47) for histology. The overall diagnostic accuracy on the cytologic and histologic examinations was 79% (37/47) and 85% (33/39) (p=0.48). According to needle type, the tissue-sampling rate for cytology and histology on each puncture was 97% (73/75) and 56% (42/75) with 25-guage needles, and was 97% (67/69) and 58% (40/69) with 22-guage needles, the accuracy of cytologic diagnosis on each puncture was 73% (53/73) with 25-gauge needles and 66% (44/67) with 22-gauge needles (p=0.37); the accuracy of histologic diagnosis on each puncture was 60% (25/42) and 75% (30/40) (p=0.14), respectively. No patient had complications. Conclusions: The tissue-sampling rate and diagnostic accuracy did not differ significantly between 22- and 25-gauge needles in patients with pancreatic or gastrointestinal diseases who underwent EUS-FNA.

Open Access Article

A head-to-head hands-on comparison of ERCP mechanical simulator (EMS) and ex vivo porcine stomach model (PSM)

Joseph W. Leung, Dong Wang, Bing Hu, Brian Lim and Felix W. Leung
Pages 108 - 113
Abstract | PDF

Background: ERCP mechanical simulator (EMS) and ex-vivo porcine stomach model (PSM) have been described. No direct comparison was reported on endoscopists’ perception regarding their efficacy for ERCP training Objective: comparative assessment of EMS and PSM. Design: Questionnaire survey before and after practice. Setting: hands-on practice workshops. Subjects: 22 endoscopists with prior experience in 111±225 (mean±SD) ERCP. Interventions: participants performed scope insertion, selective bile duct cannulation with guide wire and insertion of a single biliary stent. Simulated fluoroscopy with external pin-hole camera (EMS), or with additional transillumination (PSM) was used to monitor exchange of accessories. Main outcome measure: participants rated their understanding and confidence before and after hands-on practice, and credibility of each simulator for ERCP training. comparative efficacy of EMS and PSM for ERCP education was scored (1=not, 10=very) based on pre and post practice surveys: realism (tissue pliability, papilla anatomy, visual/cannulation realism, wire manipulation, simulated fluoroscopy, overall experience); usefulness (assessment of results, supplementing clinical experience, easy for trainees to learn new skills) and application (overall ease of use, prepare trainees to use real instrument and ease of incorporation into training). Results: Before hands-on practice, both EMS and PSM received high scores. After practice, there was a significantly greater increase in confidence score for EMS than pSM (p<0.003). participants found eMS more useful for training (p=0.017). Limitations: Subjective scores. Conclusions: Based on head-to-head hands-on comparison, endoscopists considered both EMS and PSM credible options for improving understanding and supplementing clinical ERCP training. EMS is more useful for basic learning.

Open Access Article

Removal of infused water predominantly during insertion (water exchange) is consistently associated with a greater reduction of pain score: Review of randomized controlled trials (RCTs) of water method colonoscopy

Felix W. Leung, J.O. Harker, Joseph W. Leung, Rodelei M. Siao-Salera, Surinder K. Mann, Francisco C. Ramirez, Shai Friedland, Arnaldo Amato, Franco Radaelli, Silvia Paggi, Vittorio Terruzzi and Y.H. Hsieh
Pages 114 - 120
Abstract | PDF

Introduction: Variation in the outcomes in RcTs comparing water-related methods and air insufflation during the insertion phase of colonoscopy raises challenging questions regarding the approach. This report reviews the impact of water exchange on the variation in attenuation of pain during colonoscopy by water-related methods. Methods: Medline (2008 to 2011) searches, abstracts of the 2011 Digestive Disease Week (DDW) and personal communications were considered to identify RcTs that compared water-related methods and air insufflation to aid insertion of the colonoscope. Results: Since 2008 nine published and one submitted RcTs and five abstracts of RcTs presented at the 2011 DDW have been identified. Thirteen RcTs (nine published, one submitted and one abstract, n=1850) described reduction of pain score during or after colonoscopy (eleven reported statistical significance); the remaining reports described lower doses of medication used, or lower proportion of patients experiencing severe pain in colonoscopy performed with waterrelated methods compared with air insufflation (Tables 1 and 2). The water-related methods notably differ in the timing of removal of the infused water - predominantly during insertion (water exchange) versus predominantly during withdrawal (water immersion). Use of water exchange was consistently associated with a greater attenuation of pain score in patients who did not receive full sedation (Table 3). Conclusion: The comparative data reveal that a greater attenuation of pain was associated with water exchange than water immersion during insertion. The intriguing results should be subjected to further evaluation by additional RcTs to elucidate the mechanism of the pain-alleviating impact of the water method.

Open Access Article

Removal of infused water predominantly during insertion (water exchange) is consistently associated with an increase in adenoma detection rate: Review of data in randomized controlled trials (RCTs) of water-related methods

Felix W. Leung, J.O. Harker, Joseph W. Leung, Rodelei M. Siao-Salera, Surinder K. Mann, Francisco C. Ramirez, Shai Friedland, Arnaldo Amato, Franco Radaelli, Silvia Paggi, Vittorio Terruzzi and Y.H. Hsieh
Pages 121 - 126
Abstract | PDF

Introduction: Variation in outcomes in RCTs comparing water-related methods and air insufflation raises challenging questions regarding the new approach. This report reviews impact of water exchange - simultaneous infusion and removal of infused water during insertion on adenoma detection rate (ADR) defined as proportion of patients with a least one adenoma of any size. Methods: Medline (2008-2011) searches, abstract of 2011 Digestive Disease Week (DDW) meeting and personal communications were considered to identify RCTs that compared water-related methods and air insufflation to aid insertion of colonoscope. Results: Since 2008, eleven reports of RCTs (6 published, 1 submitted and 4 abstracts, n=1728) described ADR in patients randomized to be examined by air and water-related methods. The water-related methods differed in timing of removal of the infused water - predominantly during insertion (water exchange) (n=825) or predominantly during withdrawal (water immersion) (n=903). Water immersion was associated with both increases and decreases in ADR compared to respective air method patients and the net overall change (-7%) was significant. On the other hand water exchange was associated with increases in ADR consistently and the net changes (overall, 8%; proximal overall, 11%; and proximal <10 mm, 12%) were all significant. Conclusion: comparative data generated the hypothesis that significantly larger increases in overall and proximal colon ADRs were associated with water exchange than water immersion or air insufflation during insertion. The hypothesis should be evaluated by RCTs to elucidate the mechanism of water exchange on adenoma detection.




REVIEW

Open Access Article

Learning and teaching the water method (with videos)

Shai Friedland and Felix W. Leung
Pages 127 - 129
Abstract | PDF

The water method is an insertion technique for colonoscopy which has recently become popular owing to its demonstrated ability to decrease patient pain and sedation requirements. This review focuses on learning and teaching the water method. Data from the United States and Asia suggests that trainees at all levels of experience can safely learn and utilize the water method. Demonstrated benefits in some of the reviewed studies include lessened sedation requirements, less pain for patients and increased cecal intubation rates in minimally sedated patients. These benefits are realized without compromising safety, adenoma detection rates, or procedure times.




RAPID COMMUNICATION

Open Access Article

A head-to-head comparison of the water vs. air method in patients undergoing screening colonoscopy

Francisco C. Ramirez and Felix W. Leung
Pages 130 - 135
Abstract | PDF

Background: The water method facilitates colonoscope insertion in unsedated patients. Objective: To compare quality indicators in sedated veterans. Design: performance improvement. Setting: VA endoscopy unit. Patients: 368 consecutive screening patients. Intervention: Air or water method assignment (high definition colonoscope) was based on the last digit of social security number. Measurements: Adenoma detection rate (ADR), cecal intubation rate; intubation and withdrawal times; sedation requirements and external pressure used. Results: ADR was higher with the water method (57.1% vs. 46.1%, p=0.04). After controlling for age, body mass index, smoking, alcohol, withdrawal time and quality of bowel preparation, the odds of detecting an adenoma was 81% higher with the water method (OR 1.81; 95% cI: 1.12–2.90). In the proximal colon ADR was higher with the water method (45.8% vs. 34.6%, p=0.03), including adenomas <10 mm in size (41.8% vs. 31.4%, p=0.04). The water method showed significantly longer cecal intubation time (6.9±0.3 vs. 5.3±0.3 min, p=0.0001); less external pressure used (11.9% vs. 28.3%, p=0.0001); lower need for additional sedation (17.5% vs. 27.2%, p<0.03). Limitations: predominance of males, single unblinded endoscopist with high ADR. Conclusions: The water method is an independent factor associated with significantly higher ADR. Replication by blinded colonoscopist(s) is indicated.




CASE REPORTS

Open Access Article

Pneumoretroperitoneum, pneumomediastinum and subcutaneous emphysema after colorectal endoscopic submucosal dissection (ESD) with air insuffation

Koichiro Sato, Sayo Itoh, Fumiko Shigiyama, Tomoyuki Kitagawa and Iruru Maetani
Pages 136 - 138
Abstract | PDF

Endoscopic submucosal dissection (ESD) for colorectal neoplasia is feasible by en block resection for accurate pathological diagnosis and for reducing the risk of recurrence. While effective and far less invasive then surgery, colorectal ESD carries a perforation risk of approximately 5%. That rate is high in comparison with other conventional treatments such as snare polypectomy or endoscopic mucosal resection (EMR). In this paper, we report on a case of pneumoretroperitoneum, pneumomediastinum and subcutaneous emphysema which occurred following perforation during ESD.

Open Access Article

EUS-guided transgastric drainage of caudate lobe liver abscesses

John Keohane, Christopher J. DiMaio, Mark A. Schattner and Hans Gerdes
Pages 139 - 141
Abstract | PDF

Pyogenic liver abscess is a rare but serious condition resulting in significant morbidity and mortality if left untreated1. The first line treatment for hepatic abscess is the transcutaneous or surgical approach with an 80-100% success rate2-4. However, these modalities are associated with numerous risks including bleeding, biliary peritonitis, fistula formation, and patient discomfort. The caudate lobe is anatomically difficult to access percutaneously. Given its proximity to the stomach, a transgastric approach to drainage is feasible. We report two consecutive patients who underwent EUS-guided transgastric drainage of a caudate lobe abscess.

Open Access Article

Endoscopic removal of a migrated cystogastrostomy double pigtail stent through a pancreatico-duodenal stula tract

Il Hyung Chung, Hee Wook Kim and Dong Ki Lee
Pages 142 - 144
Abstract | PDF

A common complication of pancreatitis is pseudocyst formation. Endoscopic drainage is a widely used treatment for pancreatic pseudocysts, and offers a defenitive solution in approximately 75% of cases. Drainage-related complications may be related directly to the procedure or may occur later as stents and drains migrate or erode into adjacent structures. Procedure-related complications included bleeding, pancreatitis, and infection while stent-related complications may involve dislocation or clogging with subsequent infection. This report is the rst description of the successful endoscopic removal of a migrated cystogastrostomy double pigtail stent through a pancreatico-duodenal stula tract that developed more than six years after the stent was originally misplaced into a pseudocyst.




ERRATUM

Open Access Article

Erratum to: DDW "Cutting Edge" Colonoscopy Techniques 2011 State-of-the-Art Lecture: Warm water infusion/CO2 insufflation for colonoscopy

Felix W. Leung, Joseph W. Leung, Surinder K. Mann, Shai Friedland, Francisco C. Ramirez and Snorri Olafsson

Abstract | PDF

Introduction: Variation in outcomes in RcTs comparing water-related methods and air insufflation raises challenging questions regarding the new approach. This report reviews impact of water exchange - simultaneous infusion and removal of infused water during insertion on adenoma detection rate (ADR) defined as proportion of patients with a least one adenoma of any size. Methods: Medline (2008-2011) searches, abstract of 2011 Digestive Disease Week (DDW) meeting and personal communications were considered to identify RcTs that compared water-related methods and air insufflation to aid insertion of colonoscope. Results: Since 2008, eleven reports of RcTs (6 published, 1 submitted and 4 abstracts, n=1728) described ADR in patients randomized to be examined by air and water-related methods. The water-related methods differed in timing of removal of the infused water - predominantly during insertion (water exchange) (n=825) or predominantly during withdrawal (water immersion) (n=903). Water immersion was associated with both increases and decreases in ADR compared to respective air method patients and the net overall change (-7%) was significant. On the other hand water exchange was associated with increases in ADR consistently and the net changes (overall, 8%; proximal overall, 11%; and proximal <10 mm, 12%) were all significant. Conclusion: comparative data generated the hypothesis that significantly larger increases in overall and proximal colon ADRs were associated with water exchange than water immersion or air insufflation during insertion. The hypothesis should be evaluated by RcTs to elucidate the mechanism of water exchange on adenoma detection.