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Background and Aims: Since 1985, the American Society for Gastrointestinal Endoscopy (ASGE) has awarded grants for endoscopic-related research. The goals of this study were to examine trends in ASGE grant funding and to assess productivity of previous recipients of the ASGE grant awards., Methods: This was a retrospective cohort analysis of all research grants awarded by the ASGE through 2009. Measures of academic productivity and self-assessment of the ASGE awards' impact on the recipients' careers were defined by using publicly available resources (eg, National Library of Medicine-PubMed) and administration of an electronic survey to award recipients., Results: The ASGE awarded 304 grants totaling $12.5 million to 214 unique awardees. Funding increased 7.5-fold between 1985 and 1989 (mean $102,000/year) and between 2005 and 2009 (mean $771,000/year). The majority of awardees were men (83%), were at or below the level of assistant professor (82%), with a median of 3 years of postfellowship experience at the time of the award, and derived from a broad spectrum of institutions as measured by National Institutes of Health funding rank (median 26, interquartile range [IQR] 12-64). Nineteen percent had a master's degree in a research-related field. Awardees' median publications per year increased from 3.5 (IQR 1.2-9.0) before funding to 5.7 (IQR 1.8-9.5) since funding; P = .04, and median h-index scores increased from 3 (IQR 1-8) to 17 (IQR 8-26); P < .001. Multivariate analysis found that the presence of a second advanced degree (eg, masters or doctorate) was independently predictive of high productivity (odds ratio [OR] 2.92; 95% confidence interval [CI], 1.09-7.81). Among 212 unique grant recipients, 82 (40%) completed the online survey. Of the respondents, median peer-reviewed publications per year increased from 3.4 (IQR 1.9-5.5) to 4.5 (IQR 2.0-9.5); P = .17. Ninety-one percent reported that the ASGE grant had a positive or very positive impact on their careers, and 85% of respondents are currently practicing in an academic environment. Most of the grants resulted in at least 1 peer-reviewed publication (67% per Internet-based search and 81% per survey)., Conclusions: The ASGE research program has grown considerably since 1985, with the majority of grants resulting in at least 1 grant-related publication. Overall academic productivity increased after the award, and the majority of awardees report a positive or very positive impact of the award on their careers. Medical professional societies are an important sponsor of clinical research., (Copyright © 2016. Published by Elsevier Inc.)

Background: Single-balloon enteroscopy (SBE) was introduced in 2007 to diagnose and treat small-bowel disorders. No study to date has evaluated SBE in patients with surgically altered anatomy outside of ERCP., Objective: To evaluate the efficacy, yield, and safety of SBE in patients with surgically altered anatomy., Design: Retrospective study., Setting: Tertiary-care academic medical center., Patients: All patients with altered surgical anatomy who underwent SBE at the Medical University of South Carolina from July 2007 to September 2013., Interventions: SBE., Main Outcome Measurements: Diagnostic yield, therapeutic yield, technical success, and adverse events., Results: A total of 48 patients met inclusion criteria. Mean age was 56 years (77% female). Eleven patients underwent single-balloon PEG placement, 8 single-balloon ERCP, 22 non-PEG/non-ERCP anterograde SBE, and 7 retrograde SBE. Previous surgeries included Roux-en-Y gastric bypass (n=26), small-intestine resection (n=6), colon resection (n=5), Whipple procedure (n=4), choledochojejunostomy (n=3), hepaticojejunostomy (n=1), Billroth I (n=1), Billroth II (n=1), and Puestow procedure (n=1). Procedural indications were PEG tube placement (n=11), choledocholithiasis (n=2), biliary stricture (n=2), obstructive jaundice (n=1), cholangitis (n=1), ampullary mass (n=1), sphincter of Oddi dysfunction (n=1), anemia and/or bleeding (n=15), abdominal pain (n=9), radiologic evidence of obstruction (n=3), and Peutz-Jeghers syndrome (n=2). The technical success rate was 73% in single-balloon PEG placement, 88% in single-balloon ERCP, 82% in other anterograde SBEs, and 86% in retrograde SBEs. No intraprocedural or postprocedural adverse events were observed., Limitations: Single center, retrospective study., Conclusion: SBE is safe and effective in patients with surgically altered anatomy., (Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: It is believed, based on limited observational data, that an unsuccessful attempt to place a prophylactic pancreatic stent substantially increases the risk of post-ERCP pancreatitis (PEP)., Objective: To better understand the risk of PEP in patients with failed pancreatic stent placement (FPS) and the impact of rectal indomethacin on this risk., Design: Secondary analysis of randomized, controlled trial data., Setting: University of Michigan and Indiana University., Patients: A total of 577 clinical trial participants at elevated risk for PEP., Interventions: Pancreatic stent placement., Main Outcome Measurements: Within the placebo group, we compared PEP rates in patients with FPS, patients who underwent successful stent placement, and in those without a stent attempt. We also performed a regression analysis evaluating the association between FPS and PEP. To define the protective effect of indomethacin, we repeated these analyses in the indomethacin group and in the full study cohort., Results: The incidence of PEP among patients in the placebo group who experienced FPS was 34.7%, significantly exceeding rates in patients who underwent successful stent placement (16.4%) and in those without a stent attempt (12.1%). After we adjusted for known PEP risk factors, FPS was found to be independently associated with PEP. Among the indomethacin group and in the full cohort, FPS was not associated with a higher risk of PEP., Limitations: Low event rate, FPS not prospectively captured., Conclusion: FPS appears to confer an increased risk of PEP, which is attenuated by rectal indomethacin administration. These findings highlight the importance of adequate training and proficiency before endoscopists attempt pancreatic stent placement and the routine use of rectal indomethacin in high-risk ERCP cases., (Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: Biliopancreatic-type postcholecystectomy pain, without significant abnormalities on imaging and laboratory test results, has been categorized as "suspected" sphincter of Oddi dysfunction (SOD) type III. Clinical predictors of "manometric" SOD are important to avoid unnecessary ERCP, but are unknown., Objective: To assess which clinical factors are associated with abnormal sphincter of Oddi manometry (SOM)., Design: Prospective, cross-sectional., Setting: Tertiary., Patients: A total of 214 patients with suspected SOD type III underwent ERCP and pancreatic SOM (pSOM; 85% dual SOM), at 7 U.S. centers (from August 2008 to March 2012) as part of a randomized trial., Interventions: Pain and gallbladder descriptors, psychosocial/functional disorder questionnaires., Main Outcome Measurements: Abnormal SOM findings. Univariate and multivariate analyses assessed associations between clinical characteristics and outcome., Results: The cohort was 92% female with a mean age of 38 years. Baseline pancreatic enzymes were increased in 5%; 9% had minor liver enzyme abnormalities. Pain was in the right upper quadrant (RUQ) in 90% (48% also epigastric); 51% reported daily abdominal discomfort. Fifty-six took narcotics an average of 33 days (of the past 90 days). Less than 10% experienced depression or anxiety. Functional disorders were common. At ERCP, 64% had abnormal pSOM findings (34% both sphincters, 21% biliary normal), 36% had normal pSOM findings, and 75% had at least abnormal 1 sphincter. Demographic factors, gallbladder pathology, increased pancreatobiliary enzymes, functional disorders, and pain patterns did not predict abnormal SOM findings. Anxiety, depression, and poorer coping were more common in patients with normal SOM findings (not significant on multivariate analysis)., Limitations: Generalizability., Conclusions: Patient and pain factors and psychological comorbidity do not predict SOM results at ERCP in suspected type III SOD. (, Clinical Trial Registration Number: NCT00688662.)., (Copyright © 2014 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Routine second-look endoscopy in modern-era peptic ulcer bleeding (PUB) remains controversial., Objective: To assess the effectiveness of routine second-look endoscopy in patients with PUB exhibiting high-risk stigmata after standard medical care and endoscopic therapy., Design: Comprehensive literature searches (1990-2011) were performed, seeking randomized trials comparing a routine with an as-needed second endoscopy., Main Outcome Measurements: The main outcome was rebleeding. Secondary outcomes were surgery and mortality. Subanalyses assessed the influence of study quality, rebleeding definitions, endoscopic hemostasis modality, and proton pump inhibitor (PPI) therapies. Analyses were performed with Revman 5.1. Results are shown as odds ratios (ORs) and 95% confidence intervals (CIs)., Results: Only 4 published articles completely reporting studies and 4 abstracts (of 577 citations) were included (938 patients). Rebleeding was significantly decreased by a routine second-look endoscopy (OR 0.55; 95% CI, 0.37-0.81), as was surgery (OR 0.43; 95% CI, 0.19-0.96), but not mortality (OR 0.65; 95% CI, 0.26-1.62). Results remained robust with varying definitions of rebleeding, but not with varying endoscopic hemostasis modalities and PPI therapies; the only trial in which high-dose PPI was used did not show a benefit of a second-look endoscopy. When removing the 2 trials that included patients at highest risk of rebleeding, no significant benefit attributable to a second-look endoscopy was noted (OR 0.65; 95% CI, 0.42-1.00)., Limitations: The small number of trials and patients in each of these studies., Conclusions: In the absence of high-dose PPI, especially in patients at very high risk (eg, active bleeding), routine second-look endoscopy appears effective in these selected patients with PUB. However, the generalizability of these results to the era of high-dose PPI and otherwise unselected patients with high-risk stigmata is unclear., (Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: In 2008, the American College of Gastroenterology (ACG) modified its colorectal screening guidelines regarding patients with family histories of colorectal polyps, specifically highlighting the importance of obtaining detailed history that includes the number, type, and size of adenomas found in a patient's relative. This information is then used to guide screening recommendations for these patients., Objective: To assess the proportion of patients undergoing screening colonscopy for a family history of polyps who have knowledge of their family members' colonoscopy findings., Design: Retrospective, single-center cohort pilot study., Setting: Tertiary care medical center., Patients: Patients who presented for screening colonoscopy between 2008 and 2010 with an indication of family history of polyps., Interventions: Obtain detailed history regarding patient's family history of polyps, including which family member, age of family member at diagnosis, size, type and number of polyps found., Main Outcome Measurements: Knowledge of family history., Results: Seventy-three patients were included in the study. Their knowledge of their family histories of polyps showed the following: 23.2% (17/73; 95% CI, 14%-35%) did not know which family member had polyps, 42.5% (31/73; 95% CI, 31%-55%) did not know the age at diagnosis, 71.2% (52/73; 95% CI, 59%-81%) did not know the polyp type, 90.4% (66/73; 95% CI, 81%-96%) did not know the number of polyps found, and 97.3% (71/73; 95% CI, 90%-100%) did not know the polyp size., Limitations: Retrospective study at a single tertiary referral center., Conclusions: Patients' knowledge regarding the details of their family histories of polyp data appears often unknown or incomplete. Thus, at present, it may not appear feasible or practical to incorporate this level of information in colon cancer screening guidelines., (Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Emerging evidence shows that transcranial direct current stimulation (tDCS), a minimally invasive brain stimulation technique, has analgesic effects in chronic pain patients and in healthy volunteers with experimental pain. No studies have examined the analgesic effects of tDCS immediately after surgical/endoscopic procedures. Endoscopy investigating abdominal pain, especially ERCP, can cause significant postprocedural pain., Objective: To test the feasibility, efficacy, and safety of tDCS on post-ERCP pain and analgesia use., Design: Randomized, sham-controlled, pilot study., Setting: Tertiary-care medical center., Patients: This study involved 21 patients who were hospitalized overnight for ERCP for unexplained right upper quadrant pain., Intervention: Twenty minutes of real 2.0 mA tDCS or sham (anode over left prefrontal cortex; cathode over gut-representation of right sensory cortex) immediately after ERCP., Main Outcome Measurements: Pain (visual analogue scale, McGill pain questionnaire, brief pain inventory), patient-controlled analgesia use, adverse events., Results: Real tDCS was associated with 22% less total hydromorphone use, versus sham. The slope of the cumulative patient-controlled analgesia usage curve was significantly steeper in the sham tDCS group (F [2,13] = 15.96; P = .0003). Real tDCS patients reported significantly less pain interference with sleep (t [17] = 3.70; P = .002) and less throbbing pain (t [16] = 2.37; P = .03). Visual analogue scale pain and mood scores (4 hours post-ERCP) suggested a nonsignificant advantage for real tDCS, despite less hydromorphone use. Side effects of tDCS were limited to mild, self-limited tingling, itching, and stinging under electrodes., Limitations: Small sample size, variability in chronic pain, and chronic opioid use., Conclusion: In this pilot study, tDCS appears to be safe, has minimal side effects, and may reduce postprocedural analgesia requirements and subjective pain ratings. Future studies appear warranted., (Copyright © 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Working parties of the American Society for Gastrointestinal Endoscopy (ASGE) Quality Committee recently published a proposed new lexicon for adverse events and a separate extensive review of risk factors. The complexity of procedures also affects outcomes., Objective: To establish a system for grading the complexity of endoscopic procedures., Design: Voting on levels 1 (easiest) to 4 (most difficult) on a list of possible procedures and contexts., Setting: Community and academic gastroenterologists in the United States, Canada, and Britain., Main Outcome Measurements: Median scores of votes cast., Results: Consensus list of levels 1 through 4 contexts and procedures., Limitations: Eminence rather than evidence based., Conclusions: A consensus list was developed for comments and testing to complement the proposed lexicons for adverse events and risk factors., (Copyright © 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: EUS-FNA has limitations in cancer diagnosis/staging. New contrast agents, transducers, and processors have improved the potential of contrast-enhanced harmonic (CEH)-EUS., Objective: To determine optimal settings and preliminary accuracy of CEH-EUS by using a second-generation perflutren lipid microsphere contrast agent and a prototype linear echoendoscope., Design: Prospective, comparative, pilot study., Setting: Tertiary-care medical center., Patients: This study involved patients with esophageal/pancreatic/liver tumors or adenopathy., Intervention: Contrast agent was injected (10 μL/kg intravenously in 1-2 doses), and the mechanical index was optimized over 5 cases (0.3). Intermittent/continuous imaging was used with extended pure harmonic detection., Main Outcome Measurements: Before-contrast and after-contrast predictions of neoplasia (5-point Likert scale). The reference standard was positive tissue or 6-month follow-up. Perfusion factors (sequence, pattern, washout) were noted, and phases were video recorded (arterial, venous, and postvenous)., Results: Thirty sites (7 nodes and 16 pancreatic and 7 nonpancreatic masses) were imaged in 21 patients; 21 of 30 had FNA, and 5 had surgery. Four cases (13.3%) were rated as undecided/indeterminate with EUS (vs 1 [3.3%] with CEH-EUS; P = .35). Twenty-four cases with confirmed diagnoses (12 malignant and 12 benign) were used for test performance: positive/negative predictive values for CEH-EUS were 80.0% (95% confidence interval, 51.9%-95.7%)/100.0% (95% confidence interval, 63.0%-100.0%) versus 84.6%/100.0% for EUS. Accuracies, counting "undecided" (1 in CEH-EUS and 4 in EUS) as incorrect, were 83.3% and 79.2%. In 2 cases, management would change significantly: (1) liver hemangioma, avoiding FNA; and (2) mediastinal "cyst" confirmed as solid., Limitations: Small sample. Tissue not always available., Conclusion: CEH-EUS adds minimal imaging time and is accurate, with small improvement over EUS. Added information in vascular and cystic lesions can potentially change management., (Copyright © 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Sphincter of Oddi dysfunction (SOD) is a controversial topic, especially in patients with no objective findings on laboratory or imaging studies (SOD type III). The value of ERCP manometry with sphincterotomy is unproven and carries significant risks., Objective: To describe the process of planning and initiating a randomized sham-controlled study to establish whether patients with SOD respond to sphincter ablation, and whether the outcomes are predicted by the pain patterns, presence or absence of other functional GI or psychosocial problems, or the results of manometry., Design: Planning a trial to establish which patients with "suspected SOD" (if any) respond to endoscopic sphincter ablation., Setting: Meetings and correspondence by a planning group of gastroenterologists and clinical research specialists hosted at the Medical University of South Carolina., Patients: Clarifying subject characteristics and inclusion and exclusion criteria., Interventions: Defining the questionnaires, therapies, randomizations, and numbers of subjects required by outcome measures. Defining the metrics of success and failure., Results: The planning resulted in funding for the proposed study as a cooperative agreement with the National Institute of Diabetes and Digestive and Kidney Diseases., Limitations: Lack of data required several consensus decisions in designing the protocol., Conclusion: The planning process was challenging, and some changes were needed after initiation., (Copyright © 2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Information regarding the safety and feasibility of EUS-guided FNA (EUS/FNA) in surgically altered anatomy is limited., Objective: The aim of this study was to describe EUS outcomes for Billroth I and II, Whipple, Puestow, Roux-en-Y (including gastric bypass), esophagectomy, and Nissen fundoplication surgeries., Design: Retrospective study., Setting: Single tertiary-care center., Patients: This study involved 188 EUS procedures performed in patients with surgically altered anatomy by 6 endosonographers from July 1995 to October 2008., Intervention: EUS and FNA., Main Outcome Measurements: Type of surgery, EUS indication, limitations to imaging, reasons for limitations, FNA results, and EUS/FNA complications., Results: Of 188 patients, 96 were men (mean age 57 years; range, 16-92 years). Of patients with Billroth II anatomy (n = 39), 10 had limited (common bile duct [CBD], head of pancreas [HOP]) imaging because intubation of the afferent limb failed (n = 6) or was not attempted (n = 4). Roux-en-Y (n = 18) encompased a variety of surgeries, but in general (n = 13) the proximal duodenum was not reached and the HOP and CBD were not imaged. For Roux-en-Y gastric bypass (n = 7), the HOP and CBD were not imaged, with the exception of 1 case (in which staple-line dehiscence permitted access to the proximal duodenum). For the remaining procedures, EUS and FNA were successful with few exceptions. There were no significant adverse events (95% confidence interval, 0% to 1.9%)., Limitations: Retrospective descriptive study., Conclusion: EUS is generally successful and safe in patients with surgically altered anatomy in this tertiary-care setting, and a very low rate of adverse events is possible. Exceptions included imaging the HOP and CBD after Roux-en-Y surgery. After Billroth II surgery, if the afferent limb was intubated, the majority of patients were able to have a complete pancreaticobiliary examination, including FNA., (Copyright © 2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Benign biliary strictures are typically managed endoscopically whereby an increasing size or number of plastic stents is placed at ERCP. Stents are often changed every 3 to 4 months based on the known median patency of a single biliary stent, but patency data for multiple biliary stents are lacking., Objective: To assess the incidence of occlusion-free survival of multiple plastic biliary stents and the rate of premature occlusion if left in longer than 6 months., Design: Retrospective., Setting: Tertiary-care medical center (Charleston, SC)., Patients: Consecutive patients who received multiple plastic stents for benign nonhilar biliary strictures from 1994 to 2008 were identified., Interventions: Exchange of multiple plastic biliary stents within 6 months (group 1) or 6 months or longer (group 2) after placement., Main Outcome Measurements: Symptomatic stent occlusion., Results: Seventy-nine patients with nonhilar extrahepatic benign biliary stricture underwent 125 ERCPs with multiple plastic biliary stents. Stents were scheduled for removal/exchange within 6 months in 52 patients (86 ERCPs) compared with after 6 months in 22 patients (26 ERCPs). The median interval between multiple stent placement and removal/exchange was 90 days for group 1 and 242 days for group 2. Premature stent occlusion occurred in 4 of 52 (7.7%) patients in group 1 versus 1 of 22 (4.5%) in group 2, with significantly longer occlusion-free survival in group 2 (log-rank P < .0001)., Limitations: Retrospective study at a single tertiary referral center., Conclusion: Multiple plastic biliary stents for benign nonhilar strictures were associated with a low rate of premature symptomatic stent occlusion at more than 6 months and a longer occlusion-free survival., (Copyright 2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: EUS is useful in determining mediastinal lymph node (LN) metastases in patients undergoing staging for lung cancer. However, FNA of LNs is often performed only if suspicious features are present. The utility of individual LN features in predicting malignant cytology remains unclear., Objective: To evaluate the utility of EUS-determined LN features for predicting malignant cytology., Design: Prospective observational study., Setting: Two U.S. tertiary-care centers., Patients: This study involved 425 patients with primary lung cancer who underwent EUS., Intervention: All mediastinal LNs were described according to size, shape, echogenicity, and margin characteristics. FNA was performed on LNs with any features suggestive of malignancy. EUS-guided FNA cytology was classified as benign or abnormal (suspicious/malignant). The utility of LN features in predicting malignant cytology was determined and further analyzed by logistic regression, and a predictive model was established., Main Outcome Measurements: Accuracy of individual LN features for predicting malignancy., Results: EUS detected 836 LNs in 425 patients, and FNA was obtained in 698 patients. On multivariable analysis, only round shape, a short axis of >8.3 mm, and sharp margins were predictive of malignant cytology. According to the predictive model, the calculated probability of having malignancy is less than 4% (95% confidence interval [CI], 0.022-0.064) when none of the LN features are present and 63% (95% CI, 51%-72.2%) when all features were seen., Limitations: No surgical histology as the criterion standard., Conclusion: Among patients with lung cancer, EUS features of round shape, sharp margins, and short axis of >8.3 mm are significant predictors of malignancy. The probability of malignancy is low when none of the features are present., (Copyright 2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Adhesions are common after conventional surgery; natural orifice transluminal endoscopic surgery (NOTES) avoids peritoneal disruption and may reduce adhesions., Objectives: To determine whether adhesions (and peritoneal contamination) are less common with NOTES transgastric colon injury and repair (TGCR) than with laparoscopic colon repair (LCR)., Design/setting: Porcine survival study., Interventions: After colon preparation and administration of antibiotics, forty 25-kg male pigs were randomly assigned to either TGCR or LCR. TGCR involved an endoscopic gastrotomy (needle-knife plus balloon dilation), CO(2) pneumoperitoneum, and a 2-cm needle-knife transmural incision of spiral colon. Colotomies were repaired with clips; gastrotomies were closed with clips and a detachable snare., Main Outcome Measurements: Adhesions were assessed at necropsy at 21 days; biopsy specimens were blindly reviewed. A 9-point adhesion score (density/vascularity, width, and extent) was averaged from 3 reviewers. Peritoneal lavage was sent for cell count and culture., Results: Two of 20 TGCR pigs died immediately (unrecognized preoperative autopsy-proven pneumonia). The median procedure times were 70.5 and 19.0 minutes for TGCR and LCR, respectively; weight gains were 7.1 and 8.2 kg, respectively. The median adhesion scores were 4.3 and 3.7, respectively (P = .26); subscores were similar (1.9, 1.5, 1.3 vs 1.7, 1.1, 1.0, respectively (P = .3-.6)). Peritoneal lavage bacterial growth was nonsignificantly lower after TGCR than after LCR (38.9% vs 60.0%, respectively; P = .30); administration of intragastric antibiotics did not decrease contamination. Three TGCR (vs no LCR) pigs had histologic peritonitis., Limitations: Animal model, colon prepped, injury immediately recognized., Conclusion: NOTES colon repair is feasible after transmural injury. Adhesions, histologic peritonitis, and contamination were similar to those with laparoscopy and were not helped by intragastric antibiotics., (Copyright 2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: According to national recommendations, colonoscopy withdrawal time (WT) on negative screening examinations should average more than 6 minutes because this time is associated with a higher rate of polyp detection. Attempts have been made to increase the WT; however, simply knowing that a quality measure, such as the WT, is being monitored, by itself, may improve the quality of an examination., Objective: To measure changes in the polyp detection rate associated with recording the WT., Design: Retrospective., Setting: Single tertiary care center., Patients: Patients undergoing colonoscopy within 5 months immediately before (group A) and after (group B) initiation of WT recording. Colonoscopies were excluded if procedure times were incomplete, missing, or nonsensical., Main Outcome Measurements: Polyp detection, compared by using the chi(2) test and logistic regression multivariate analyses; pathology manually reviewed from a sample of 200 consecutive polyp cases (100 per group)., Results: The average WT in group B was 14.5 minutes (11.0 minutes in negative screening examinations). In group A, polyps were detected in 530 (37.7%) of 1405 colonoscopies compared with 571 (41.2%) of 1387 colonoscopies in group B (difference 3.5%; 95% CI, -0.2% to 7.1%), a nonsignificant 9.3% relative increase. Longer procedure time, age, sex, and indication were significant predictors; monitoring the WT was not. Nonsignificantly, more polyp examinations in group B found all nonadenomas compared with group A (36% vs 27%; P = .17), and polyps were nonsignificantly smaller (P = .30)., Limitations: Retrospective database data, pathology performed only on a subsample., Conclusion: WT recording was associated with a nonsignificant increase in polyp detection, but this was likely attributable to a slight increase in the detection of (smaller) nonadenomatous polyps., (Copyright 2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Complications of ERCP are an important concern. We sought to determine predictors of post-ERCP complications at our institution., Methods: GI TRAC is a comprehensive data set of patients who underwent ERCP at our institution from 1994 through 2006. Logistic regression models were used to evaluate 4 categories of complications: (1) overall complications, (2) pancreatitis, (3) bleeding, and (4) severe or fatal complications. Independent predictors of complications were determined with multivariable logistic regression., Results: A total of 11,497 ERCP procedures were analyzed. There were 462 complications (4.0%), 42 of which were severe (0.36%) and 7 were fatal (0.06%). Specific complications of pancreatitis (2.6%) and bleeding (0.3%) were identified. Overall complications were statistically more likely among individuals with suspected sphincter of Oddi dysfunction (SOD) (odds ratio [OR] 1.91) and after a biliary sphincterotomy (OR 1.32). Subjects with a history of acute or chronic pancreatitis (OR 0.78) or who received a temporary small-caliber pancreatic stent (OR 0.69) had fewer complications. Post-ERCP pancreatitis was more likely to occur after a pancreatogram via the major papilla (OR 1.70) or minor papilla (OR 1.54) and among subjects with suspected SOD with stent placement (OR 1.45) or without stent placement (OR 1.84). Individuals undergoing biliary-stent exchange had less-frequent pancreatitis (OR 0.38). Biliary sphincterotomy was associated with bleeding (OR 4.71). Severe or fatal complications were associated with severe (OR 2.38) and incapacitating (OR 7.65) systemic disease, obesity (OR 5.18), known or suspected bile-duct stones (OR 4.08), pancreatic manometry (OR 3.57), and complex (grade 3) procedures (OR 2.86)., Conclusions: This study characterizes a large series of ERCP procedures from a single institution and outlines the incidence and predictors of complications.

Background: Pancreatic sphincterotomy is one of several factors associated with an increased risk of post-ERCP pancreatitis (PEP). The needle-knife pancreatic sphincterotomy technique (NKS) is purported to result in less-frequent post-ERCP pancreatitis compared with a standard pull-type sphincterotomy (PTS)., Objective: Our purpose was to analyze the experience with both endoscopic pancreatic sphincterotomy (EPS) techniques with respect to post-ERCP pancreatitis at a single tertiary-level referral center., Design: Retrospective analysis., Setting: Tertiary-care medical center (Charleston, South Carolina)., Patients: Patients without chronic pancreatitis and with normal retrograde pancreatogram who underwent EPS between 1994 and 2007 were identified. Patients were excluded for the following reasons: pancreatic stent not placed, both sphincterotomy techniques used, any balloon dilation of the ampullary orifice, precut or access papillotomy, pancreas divisum., Results: A total of 481 patients were identified and underwent 510 ERCPs. Indications for ERCP were recurrent pancreatic-type pain (n = 353) or pancreatitis (n = 157). NKS was used for 395 of 510 (77.5%) cases versus 115 of 510 (22.5%) in which PTS was used. The incidence of post-ERCP pancreatitis was no different between NKS (25/395, 6.4%) and PTS (9/115, 7.8%). Most cases were mild pancreatitis; a single episode of severe PEP occurred in each group., Conclusions: The risk of post-ERCP pancreatitis does not differ between EPS techniques when performed at a high-volume pancreaticobiliary referral center when using routine prophylactic pancreatic duct stent placement.

Background: EUS is increasingly used in the diagnosis of chronic pancreatitis (CP). A number of publications in this field have used different EUS terminology, features, and criteria for CP, making it difficult to reproduce their findings and apply them in clinical practice. Moreover, traditional criteria such as the Cambridge classification for CP are arguably outdated and have lost their relevance., Objective: Our purpose was to establish consensus-based criteria for EUS features of CP., Design: Consensus study., Main Outcome Measurements: Thirty-two internationally recognized endosonographers anonymously voted on terminology of EUS features, rank order, and category (major vs minor criteria). Consensus was defined as greater than two thirds agreement among participants., Results: Major criteria for CP were (1) hyperechoic foci with shadowing and main pancreatic duct (PD) calculi and (2) lobularity with honeycombing. Minor criteria for CP were cysts, dilated ducts > or =3.5 mm, irregular PD contour, dilated side branches > or =1 mm, hyperechoic duct wall, strands, nonshadowing hyperechoic foci, and lobularity with noncontiguous lobules., Limitation: Lack of broadly accepted reference standard., Conclusion: In a complex disease such as CP that has no universally accepted reference standard, an EUS-based criterion for diagnosis can be determined by expert consensus opinion and the existing body of evidence. Here we present the new "Rosemont criteria" for the EUS diagnosis of CP.

Background: Infection is a known complication of ERCP procedures, and the role of antibiotic prophylaxis is uncertain., Objective: To document the incidence of infection after ERCP while changing the policy for antibiotic prophylaxis., Design: Retrospective analysis of data collected prospectively on infection complications, with progressive reduction in the use of prophylactic antibiotics., Setting: Single-center university referral hospital., Patients: A total of 11,484 ERCP procedures were documented prospectively over a period of 11 years., Interventions: After baseline assessment, the use of prophylactic antibiotics was sequentially reduced and simplified in 3 phases., Main Outcome Measurements: Incidence of infection, categorized by severity., Results: The infection rate was low overall and decreased significantly with time, from 0.48% to 0.25%, despite a marked reduction in the proportion of patients given antibiotics (from 95% to 25%). Multivariate analysis also showed that the only category of patients at increased risk for infection (despite antibiotics) was the subgroup undergoing interventions for biliary problems after liver transplantation., Limitations: A lack of routine follow-up may mean that some delayed infectious complications were not recorded. The low risk of infection in this series may reflect the high technical success rate for relief of biliary obstruction; thus, our current minimalist antibiotic policy may not be generalizable to community practice., Conclusions: Infectious complications of ERCP can be kept to a minimum with a limited use of prophylactic antibiotics.

Background: EUS is a promising modality for pancreatic-cancer screening in high-risk persons, including familial pancreatic-cancer (FPC) kindreds., Objective: To assess interobserver agreement for interpretation of EUS in persons at high risk for pancreatic cancer., Design: Seventeen expert endosonographers blinded to patients' clinical history rated a "training set" of pancreatic EUS video clips for the presence of a normal examination, masses, cysts, and features of chronic pancreatitis. Clips included high-risk persons and controls (normal and various pancreatic diseases). The endosonographers then participated in a workshop on EUS findings in high-risk persons and drafted a consensus statement. Three months later, they blindly rated a "test set" composed of the same video clips., Main Outcome Measurements: Interobserver agreement at baseline (training set) and after a consensus process (test set)., Results: For the training set, interobserver agreement was good (kappa>or=0.4) for the presence of cysts and was fair to poor for all other rated EUS features and diagnosis of normal. There was no overall improvement in the test set. In both the training and test sets, agreement was worse for clips from FPC kindreds (kappa>or=0.4 for cysts and <0.4 for all other features) than for controls (kappa>or=0.4 for normal, cysts, masses, echogenic strands, and lobularity)., Limitations: Video clips were not of identical image quality and duration as a clinical EUS examination., Conclusions: There was fair to poor interobserver agreement for the interpretation of pancreatic EUS video clips from members of FPC kindreds. Agreement was not improved by a consensus process.

Background: EUS has been proposed as a minimally invasive and accurate test to detect chronic pancreatitis (CP)., Objective: To investigate the correlation between EUS criteria and histopathology grading in patients with presumed CP., Design: Retrospective study., Setting and Patients: Patients who received pancreatic surgery according to presumed CP from the Medical University of South Carolina surgical database between 1995 and 2003 were identified and included if EUS was performed within 1 year before surgery. The number of EUS criteria for CP was compared with a histologic fibrosis score (FS)., Main Outcome Measurements: Sensitivity and specificity of number of EUS criteria compared with FS., Results: Seventy-one patients were identified (38 women). Median FS was 7 (range, 0-12). Of the patients with calcifications: calcifications were detected by EUS in 30 (42%), 14 (47%) had calcifications missed by other imaging modalities, and 28 (93%) were confirmed to have abnormal histology (FS > or = 2). Of the patients without calcifications: in the 41 patients without calcifications on EUS, 36 (88%) had FS > or = 2; median FS was 5 (range, 0-12); the correlation between the number of EUS criteria and FS was low but statistically significant (r = 0.40; P = .01). Three or more EUS criteria provided the best balance of sensitivity (83.3%) and specificity (80.0%) for predicting abnormal histology., Limitations: Retrospective study. All patients were believed to need surgery., Conclusions: A threshold of 3 or more EUS criteria provides the best balance of sensitivity and specificity for histologic pancreatic fibrosis. Calcifications seen by EUS but missed by other imaging are common in this group of patients.

Background: Technical options for pancreatic sphincterotomy of the minor papilla for pancreas divisum include a needle-knife cut over a plastic stent and a standard pull-type cut with a sphincterotome., Objective: Our objective was to compare the frequency, safety, and intermediate-term efficacy of these 2 techniques at our institution., Patients and Methods: Retrospective review of the GI-Trac database from July 1994 to July 2004 for patients with pancreas divisum undergoing an initial minor papilla sphincterotomy., Interventions: Patients were separated into 2 groups on the basis of the endoscopic pancreatic sphincterotomy technique used, either a needle-knife sphincterotomy (NKS) or standard pull-type sphincterotomy (PTS). The groups were compared on the basis of need for any reintervention, restenosis rates, and complication rates with use of Cox proportional hazards models., Results: There were 133 patients (72%) in the NKS group and 51 (28%) in the PTS group. Clinical presentations were similar in the 2 groups. At a median follow-up of 5 years, additional endoscopic therapy including repeat endoscopic pancreatic sphincterotomy, endoscopic balloon dilation, stone extraction, or stenting was necessary in 29% of patients after NKS and in 26% after PTS. Papillary restenosis rates were 24% over a median follow-up of 6 years after NKS and 20% over a median follow-up of 5 years after PTS. Overall complication rates were similar in those undergoing NKS and PTS (8.3% vs 7.8%). Age less than 40 years independently predicted reintervention (hazard ratio 2.21) and restenosis (hazard ratio 2.41) (both P < .01)., Conclusions: NKS is used more than PTS for minor papilla sphincterotomy at our institution, but the 2 techniques appear equally safe and effective. Younger age may be associated with higher reintervention rates.

Background: ERCP is used selectively in patients with acute biliary pancreatitis (ABP). In patients with ABP, ERCP often is difficult and has the potential to cause further damage. In addition, the prevalence of residual choledocholithiasis in ABP is low (<30%). EUS and MRCP accurately diagnose choledocholithiasis, but the performance of MRCP may be inferior in ABP. EUS, with ERCP when a stone is seen, has been shown to be feasible. This study assessed the relative costs and outcomes of EUS and MRCP in patients with ABP compared with standard care involving selective ERCP., Methods: A decision tree was constructed, modeling standard care for nonsevere ABP (selective ERCP) and severe ABP (ERCP with sphincterotomy and balloon sweep). The other arms included either EUS or MRCP first, with the conversion to or the addition of ERCP when a bile-duct stone was seen. Probabilities and accuracy of EUS and MRCP were taken from published data. Costs were locally quantified in Canadian dollars (CDN), including nursing/technical/professional personnel, equipment maintenance, and disposable equipment. The robustness of assumptions was tested by sensitivity analyses., Results: Overall, EUS in all patients with ABP was marginally dominant compared with standard care with selective ERCP ($58 CDN per patient less expensive; 0.9% fewer cases of pancreatitis [ERCP-related or recurrent]). In the severe ABP subgroup, EUS was more clearly dominant ($742 CDN per patient less expensive; 3% fewer cases of pancreatitis), and the nonsevere subgroup had an incremental cost-effectiveness ratio of $17,000 per case of pancreatitis avoided. MRCP was more expensive than EUS in both subgroups., Conclusions: EUS is dominant in severe ABP. In nonsevere ABP, it is slightly more costly but is associated with fewer ERCPs and ERCP-related complications. A randomized trial would help to quantify the benefits of avoiding ERCP in these patients.

Background: Conventional CT is insensitive for detection of metastatic involvement of celiac lymph nodes in esophageal cancer. Helical CT has theoretical advantages over "slice" CT in this regard, but its performance has not yet been prospectively studied., Methods: Consecutive patients with untreated esophageal cancer were recruited after obtaining informed consent. Helical CT was performed on all patients and TNM staging was performed by a single radiologist. Subsequently, all patients underwent esophageal radial and, as needed, curvilinear array EUS with fine needle aspiration (FNA), for evaluation of celiac lymph nodes and TNM staging. Test performance characteristics with 95% confidence intervals were calculated, assuming EUS with FNA as the reference standard., Results: Forty-eight patients were recruited, of whom 37 (77%) were men. The mean (SD) age was 63.6 (10) years. Excluding 5 patients in whom a confirmatory FNA was not available (n = 43), helical CT identified celiac lymph nodes in 12 (28%) patients. The reference standard of EUS with FNA identified 15 (35%) patients with metastatic celiac lymph nodes, giving a sensitivity, specificity, and positive and negative predictive values for helical CT of 53% (95% CI [28%, 79%]), 86% (95% CI [73%, 99%]), 67% (95% CI [40%, 93%]), and 77% (95% CI [63%, 92%]), respectively, for assessing celiac lymph nodal involvement. The sensitivity and specificity of helical CT in detecting T4 disease were 25% (95% CI [3.8%, 46%]) and 94% (95% CI [85%, 100%]), respectively. There were 12 patients (25%; 95% CI [13%, 37%]) who were felt to have resectable disease by helical CT but had either metastatic involvement of celiac lymph nodes or T4 disease by EUS/FNA., Conclusions: Despite technological advances, helical CT still appears unreliable, mainly because of insensitivity, for the identification of inoperable T4 or metastatic involvement of celiac lymph node disease in esophageal cancer.