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1.  A prospective study of obesity, weight change and the risk of adenoma recurrence 
Endoscopy  2012;44(9):813-818.
Background and study aims
Obesity is a risk factor for colorectal neoplasia. Lifestyle modifications including weight loss have been advocated to reduce the risk. However, no prospective study has evaluated if weight loss actually affects adenoma recurrence. We examined whether weight change (loss or gain) over four years is associated with adenoma recurrence.
Patients and methods
1,826 participants with colorectal adenoma in the Polyp Prevention Trial had height and weight measured at baseline. Adenoma recurrence was determined by end of trial colonoscopy 4 years after study entry when participants’ weights were re-measured. We used Poisson regression models to evaluate body mass index (BMI), weight change over 4 years and the risk of any adenoma and advanced adenoma recurrence.
723 (39.6%) participants had adenoma recurrence, of whom 118 (6.5%) had advanced adenoma recurrence. Among those with baseline BMI < 25 kg/m2 (n=466), BMI = 25–29 kg/m2 (n=868), and BMI ≥ 30 kg/m2 (n=492), the recurrence rate was 34.5%, 41% and 41.9%, respectively. Obesity was associated with an increased risk of adenoma (RR=1.19; 95%CI: 1.01–1.39) and advanced adenoma recurrence (RR=1.62; 95%CI: 1.01–2.57). However, when compared with those with relatively stable weight (< 5 pound weight change) over the 4-year trial, weight gain or loss was not associated with adenoma recurrence. This was consistent, regardless of the baseline BMI.
Weight loss or gain over 4 years does not affect adenoma recurrence. Our study does not support weight loss alone as an effective intervention for reducing adenoma recurrence.
PMCID: PMC3910085  PMID: 22926666
Adenomatous polyps; body mass index; colonoscopy; weight loss
2.  Constipation is not associated with an increased rate of findings on colonoscopy: results from a national endoscopy consortium 
Endoscopy  2010;42(3):10.1055/s-0029-1243843.
Background and study aims
There are no definite guidelines regarding colonoscopic evaluation for the indication of constipation, a common gastrointestinal complaint. The aim of our study was to determine the risk of finding significant lesions in patients undergoing colonoscopy for the indication of constipation alone compared with constipation with another indication or average-risk screening.
Patients and methods
A retrospective review of the Clinical Outcomes Research Initiative database was carried out for colonoscopies undertaken between 1 January 2000 and 30 June 2003. A total of 41,775 index colonoscopies performed for the indications of average-risk screening, constipation only or constipation with another indication were identified. Logistic regression analyses were performed for constipation alone versus constipation with another indication, and for constipation alone versus average-risk screening.
Constipation alone did not show any increased risk of significant findings on colonoscopy. Constipation and the presence of another indication, however, had a statistically significant increased risk of a significant finding on colonoscopy. The indication of constipation alone had a lower risk of significant findings on colonoscopy compared with average-risk screening. Variations in the definition of constipation used was a limitation of the study.
Colonoscopy for constipation alone has a lower yield for significant findings compared with average-risk screening and constipation with another indication; hence, colonoscopy should not be done for constipation alone.
PMCID: PMC3846169  PMID: 20101567
3.  The Significance of Gastric and Duodenal Histological Ischemia Reported on Endoscopic Biopsy. A Case Series 
Endoscopy  2011;43(4):10.1055/s-0030-1256040.
It is unknown whether pathological reports of ischemia obtained from gastroduodenal biopsy suggests a diagnosis, prognosis or requires additional evaluation. The aim of this study was to review the natural history, clinical presentation, endoscopic appearance, treatments and major clinical outcomes of patients with gastroduodenal ischemia. Case series of fourteen patients with variable etiologies, seven patients with gastric and seven patients with duodenal origin were obtained from a search of our endoscopic pathologic database for reports of histological ischemia. The most common indication for upper endoscopy was upper gastrointestinal bleeding (71%). Half of the endoscopic lesions appeared very severe. There were six cases of rebleeding (43%) and four deaths (29%). CT scanning was frequently used (12 cases, 86%), but was diagnostic in only three cases. Patients with underlying vascular pathology have substantial 6-month mortality (29%).
PMCID: PMC3816952  PMID: 21360426
4.  Severe Upper Gastrointestinal Hemorrhage from Linear Gastric Ulcers in Large Hiatal Hernias: a Large Prospective Case Series of Cameron Ulcers 
Endoscopy  2013;45(5):397-400.
Background and study aims
Cameron ulcers are a rare but clinically significant cause of severe upper gastrointestinal hemorrhage (SUGIH). Our aims were to describe (1) the diagnosis, treatment and outcomes of patients with Cameron ulcers causing hospitalization for SUGIH, (2) the differences between patients with occult vs. overt bleeding and (3) between patients treated surgically and medically.
Patients and methods
Over the past 17 years, all consecutive patients hospitalized in our two tertiary referral medical centers for severe UGIH or severe obscure GIH and entered into our large prospective databasis were screened for Cameron ulcer diagnosis.
Cameron ulcers were diagnosed in 25 patients of 3960 patients with SUGIH (0.6%). 21 patients had follow-up (median [IQR] time of 20.4 months [8.5–31.8]). Patients were more often elderly females with chronic anemia, always had large hiatal hernias, and were usually referred for obscure SUGIH. Twelve (57.2%) patients were referred to surgery for rebleeding and recurrent blood loss while treated with high dose of proton pump inhibitors (PPI). 9 (42.8%) other patients continued PPI without any rebleeding during the follow-up. Patients with overt bleeding had significantly more prior hospitalizations for SUGIH, more often stigmata of hemorrhage on ulcers, and more red blood cell transfusions than patients with occult bleeding. However, there was no difference in rebleeding and mortality rates between the two groups.
Cameron ulcers in large hiatal hernias are an uncommon cause of SUGIH. Most of patients are referred for obscure GIH. The choice of medical vs. surgical therapy should be individualized.
PMCID: PMC3804305  PMID: 23616128
Cameron ulcers; hiatal hernia; gastrointestinal bleeding; anemia; fundoplication
5.  Depth of resection using two different endoscopic mucosal resection techniques 
Endoscopy  2008;40(5):395-399.
Background and study aims
Endoscopic mucosal resection (EMR) has been carried out for high-grade dysplasia (HGD) and intramucosal carcinoma (IMCA) in Barrett’s esophagus using two different cap-assisted techniques, the “inject, suck, and cut“ and the “band and snare.“ Previous work has demonstrated comparable specimen diameters. However, the two techniques have not been previously compared with respect to depth of resection.
Patients and methods
From a database of patients with Barrett’s esophagus, we identified 40 consecutive specimens removed using EMR from patients with HGD or IMCA, 20 each from the “inject, suck, and cut” and the “band and snare” techniques. Specimens were evaluated and measured separately by two pathologists for greatest diameter and depth, and for the presence of submucosa and muscularis propria at the deepest margin of resection. Follow-up data were collected regarding clinical outcome and stricture formation.
The mean depth of the specimens from the two techniques was not significantly different (0.51 cm vs. 0.50 cm, P = 0.76). All specimens contained substantial submucosa, allowing accurate staging of the neoplastic lesions resected. Muscularis propria was identified at the base of 65% of the “band and snare” and 50% of the “inject, suck, and cut” specimens (P = 0.52).
The “inject, suck, and cut” and “band and snare” techniques both yield equivalent adequate depth of histological specimens from Barrett’s esophagus with HGD or IMCA, and both provide accurate pathological staging.
PMCID: PMC3712272  PMID: 18494133
6.  Prophylactic 5-Fr pancreatic duct stents are superior to 3-Fr stents: a randomized controlled trial 
Endoscopy  2011;43(4):325-330.
Temporary prophylactic pancreatic duct stenting effectively reduces post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk patients, but the optimal stent remains unclear. We compared rate of spontaneous passage, and technical difficulty of placement for 3-Fr and 5-Fr stents.
A randomized controlled trial at a single academic medical center. Patients deemed high risk for PEP randomly received 5-Fr or 3-Fr pancreatic duct stents. Primary outcome was spontaneous stent passage by 2 weeks. Secondary outcomes were ease and time for stent placement, and number of guide wires required for the entire procedure.
Patients (69 female [89%]; mean age 44.9 years, standard deviation [SD] 16.8) were randomly assigned to receive 5-Fr (n = 38) and 3-Fr (n = 40) stents. Indications for stenting were similar. Seven patients in the 3-Fr group actually received a 5-Fr stent, and two in the 5-Fr group had a 3-Fr stent. Spontaneous passage or non-passage was confirmed in 64 (83%). No statistically significant difference in spontaneous passage rates was seen (5-Fr group, 68.4%; 3-Fr group 75.0%; P = 0.617). Non-passage rates were 10.5% (5-Fr group) and 10.0% (3-Fr group) (P = 1.00). The study was stopped after a futility analysis for the primary end point. Placement of 5-Fr stents was rated easier, at a mean score of 1.8 (5-Fr) vs. 3.4 (3-Fr), P < 0.001, with a trend towards being faster, 9.2 vs. 11.1 minutes (P = 0.355). Fewer guide wires were required for 5-Fr stent placement, 1.5 vs. 1.9 (P = 0.002). PEP rates did not differ (P = 0.519).
Placement of 5-Fr compared to 3-Fr pancreatic duct stents for PEP prophylaxis is easier, faster, and requires fewer wires. No statistically significant difference in spontaneous passage was found between the two sizes.
PMCID: PMC3514442  PMID: 21455872
7.  Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED) 
Endoscopy  2011;44(1):74-94.
Atrophic gastritis, intestinal metaplasia, and epithelial dysplasia of the stomach are common and are associated with an increased risk for gastric cancer. In the absence of guidelines, there is wide disparity in the management of patients with these premalignant conditions. The European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter Study Group (EHSG), the European Society of Pathology (ESP) and the Sociedade Portuguesa de Endoscopia Digestiva (SPED) have therefore combined efforts to develop evidence-based guidelines on the management of patients with precancerous conditions and lesions of the stomach (termed MAPS). A multidisciplinary group of 63 experts from 24 countries developed these recommendations by means of repeat online voting and a meeting in June 2011 in Porto, Portugal. The recommendations emphasize the increased cancer risk in patients with gastric atrophy and metaplasia, and the need for adequate staging in the case of high grade dysplasia, and they focus on treatment and surveillance indications and methods.
PMCID: PMC3367502  PMID: 22198778
8.  Reflux and Barrett’s disease 
Endoscopy  2011;43(1):21-25.
PMCID: PMC3073694  PMID: 21234837
9.  Quality of Life Following Radiofrequency Ablation of Dysplastic Barrett’s Esophagus 
Endoscopy  2010;42(10):790-799.
Background and study aims
The impact of the diagnosis and treatment of dysplastic Barrett’s esophagus (BE) on quality of life (QoL) is poorly understood. This study assessed the influence of dysplastic BE on QoL and evaluated if endoscopic treatment of dysplastic BE with radiofrequency ablation (RFA) improves QoL.
Patients and methods
We analyzed changes in QoL in the AIM Dysplasia Trial—a multicenter study of patients with dysplastic BE randomized to RFA therapy or a sham intervention. We developed a 10-item questionnaire to assess the influence of dysplastic BE on QoL. The questionnaire was completed by subjects at baseline and 12 months.
One hundred and twenty-seven patients were randomized to RFA (n=84) or sham (n=43). At baseline, the majority of subjects reported esophageal cancer worry (71% RFA, 85% sham) and esophagectomy worry (61% RFA, 68% sham). Subjects reported depression, impaired QoL, worry, stress and dissatisfaction with the condition of their esophagus. Of those randomized, 117 subjects completed the 12 month endpoint. Compared to sham, subjects treated with RFA had significantly reduced esophageal cancer worry (p=0.003) and esophagectomy worry (p=0.009). They also had significantly reduced depression (p=0.02), general worry with the condition of their esophagus (p≤0.001), impact on daily QoL (p=0.009), stress (p=0.03), dissatisfaction with the condition of their esophagus (p≤0.001) and impact on work and family life (p=0.02).
Inclusion in the treatment group of this randomized, sham-controlled trial of RFA was associated with improvement in disease-specific health-related quality of life. This improvement appears secondary to a perceived decrease in the risk of cancer.
PMCID: PMC3099136  PMID: 20886398
10.  Interobserver reliability in the endoscopic diagnosis and grading of Barrett’s esophagus: an Asian multi-national study 
Endoscopy  2010;42(9):699-704.
Background and study aim
The establishment of precise and valid diagnostic criteria is the first step towards understanding the pathogenesis of Barrett’s esophagus in Asia. The present study determined the interobserver reliability in the endoscopic diagnosis and grading of Barrett’s esophagus among Asian endoscopists.
Patients and methods
Video clips of endoscopy in 21 patients with and without Barrett’s esophagus were used for training (n=3) and standardized diagnosis and grading (n=18) of Barrett’s esophagus by endoscopists from seven hospitals in different Asian regions/countries. Barrett’s esophagus, where present, was graded using the Prague C & M Criteria whereby the circumferential extent of Barrett’s segment (C value), maximum extent of Barrett’s segment (M value), location of the gastroesophageal junction, and location of the diaphragmatic hiatus were scored. The intraclass correlation coefficients (ICC) were calculated as a measure of interobserver reliability.
A total of 34 endoscopists participated. The ICC values for the scores of C value, M value, location of the gastroesophageal junction, and location of the diaphragmatic hiatus were 0.92 (95% CI, 0.88–0.97), 0.94 (0.90–0.98), 0.86 (0.78–0.94), and 0.81 (0.71–0.92), respectively, indicating excellent interobserver reliability. The differences in region/country, experience of endoscopists, volume of participating center, or the primary practice type did not have significant effect on the reliability. The ICC values for recognition of Barrett’s esophagus with an extent ≥1 cm were 0.90 (0.80–1.00) and 0.92 (0.87–0.98) for the C and M values, respectively, whereas the corresponding ICC values for Barrett’s segment <1 cm were 0.18 (0.03–0.32) and 0.21 (0.00–0.51), respectively.
Despite the relatively uncommon occurrence of Barrett’s esophagus in Asia, endoscopists in our study exhibited excellent consistency in the endoscopic diagnosis and grading of Barrett’s esophagus using the Prague C & M Criteria. In view of the low interobserver reliability in recognizing Barrett’s esophagus segments of <1 cm, future studies in Asia should take this into account in their selection strategies as to recruit as homogeneous a population for study as possible.
PMCID: PMC3000217  PMID: 20806154
11.  The role of a computed tomography-based image registered navigation system for natural orifice transluminal endoscopic surgery: a comparative study in a porcine model 
Endoscopy  2010;42(12):1096-1103.
Background and study aims
Most natural orifice transluminal endoscopic surgery (NOTES) procedures have been performed in animal models through the anterior stomach wall, but this approach does not provide efficient access to all anatomic areas of interest. Moreover, injury of the adjacent structures has been reported when using a blind access. The aim of the current study was to assess the utility of a CT-based (CT: computed tomography) image registered navigation system in identifying safe gastrointestinal access sites for NOTES and identifying intraperitoneal structures.
A total of 30 access procedures were performed in 30 pigs: anterior gastric wall (n = 10), posterior gastric wall (n = 10), and anterior rectal wall (n = 10). Of these, 15 procedures used image registered guidance (IR-NOTES) and 15 procedures used a blind access (NOTES only). Timed abdominal exploration was performed with identification of 11 organs. The location of the endoscopic tip was tracked using an electromagnetic tracking system and was recorded for each case. Necropsy was performed immediately after the procedure. The primary outcome was the rate of complications; secondary outcome variables were number of organs identified and kinematic measurements.
A total of 30 animals weighting a mean (± SD) of 30.2 ± 6.8 kg were included in the study. The incision point was correctly placed in 11 out of 15 animals in each group (73.3 %). The mean peritoneoscopy time and the number of properly identified organs were equivalent in the two groups. There were eight minor complications (26.7 %), two (13.3 %) in the IR-NOTES group and six (40.0 %) in the NOTES only group (P = n. s.). Characteristics of the endoscope tip path showed a statistically significant improvement in trajectory smoothness of motion for all organs in the IR-NOTES group.
The image registered system appears to be feasible in NOTES procedures and results from this study suggest that image registered guidance might be useful for supporting navigation with an increased smoothness of motion.
PMCID: PMC3061238  PMID: 20960391
12.  Three-dimensional optical coherence tomography of Barrett’s esophagus and buried glands beneath neo-squamous epithelium following radiofrequency ablation 
Endoscopy  2009;41(9):773-776.
We report three-dimensional (3D) endoscopic microscopy findings in Barrett’s esophagus, using an endoscopic optical coherence tomography (OCT) system in one patient before and in one patient after radiofrequency ablation (RFA). Findings were compared with those in a normal patient without Barrett’s esophagus. In the normal patient, findings were of regular flat squamous mucosa with small subepithelial vessels and glands. In the Barrett’s esophagus patient, findings were of large, densely packed glands with distortion of mucosal architecture. In the post-RFA case, findings were of a small number of isolated glands buried beneath 300–500 μm of neosquamous epithelium and lamina propria. Neosquamous epithelium is a marker of successful ablative therapy, while buried glands may have potential for dysplastic progression and are difficult to detect using conventional methods. These results indicate a potential role of 3D-OCT endoscopic microscopy for follow-up, including subsurface assessment, of ablative treatments for Barrett’s esophagus.
PMCID: PMC2890226  PMID: 19746317
14.  Photodynamic therapy for Barrett’s esophagus: does light still have a role? 
Endoscopy  2008;40(12):1021-1025.
Photodynamic therapy was the first treatment to have been shown to significantly decrease high-grade dysplasia and cancer in patients with Barrett’s esophagus. However, its use has been limited, primarily because of the side effects, which include esophageal strictures, cutaneous photosensitivity, chest pain, and nausea and vomiting [1]. The tolerability aspects of photodynamic therapy, as well as the dosimetry, though, can be improved with existing technologies to further develop this therapy into truly a widely applicable therapy. Studies have recently been done to help identify patients more likely to suffer stricture after photodynamic therapy. In addition, there has been evidence to suggest that the efficacy of photodynamic therapy also can be limited by genetic abnormalities in the mucosa. By combining knowledge of tissue biology, optical properties of the tissue, and dosimetry issues with ablation, photodynamic therapy can still have a potentially bright future.
PMCID: PMC2676574  PMID: 19065486

Results 1-14 (14)