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The introduction of new technologies in endoscopy has been met with uncertainty, skepticism, and lack of standardization or training parameters, particularly when disruptive devices or techniques are involved. The widespread availability of a novel endoscopic suturing device (OverStitch™) for tissue apposition has enabled the development of applications of endoscopic suturing.The American Gastroenterological Association partnered with Apollo Endosurgery to develop a registry to capture in a pragmatic non-randomized study the safety, effectiveness, and durability of endoscopic suturing in approximating tissue in the setting of bariatric revision and fixation of endoprosthetic devices.We highlight the challenges of the adoption of novel techniques by examining the process of developing and executing this multicenter registry to assess real-world use of this endoscopic suturing device. We also present our preliminary data on the safety and effectiveness of the novel device as it is applied in the treatment of obesity.The Prospective Registry for Trans-Orifice Endoscopic Suturing Applications (ES Registry) was an effective Phase 4, postmarketing registry aimed at capturing pragmatic, real-world use of a novel device. These findings serve to solidify the role of endoscopic suturing in clinical practice.

BACKGROUND In the National Polyp Study (NPS), colorectal cancer was prevented by colonoscopic removal of adenomatous polyps. We evaluated the long-term effect of colonoscopic polypectomy in a study on mortality from colorectal cancer. METHODS We included in this analysis all patients prospectively referred for initial colonoscopy (between 1980 and 1990) at NPS clinical centers who had polyps (adenomas and nonadenomas). The National Death Index was used to identify deaths and to determine the cause of death; follow-up time was as long as 23 years. Mortality from colorectal cancer among patients with adenomas removed was compared with the expected incidence-based mortality from colorectal cancer in the general population, as estimated from the Surveillance Epidemiology and End Results (SEER) Program, and with the observed mortality from colorectal cancer among patients with nonadenomatous polyps (internal control group). RESULTS Among 2602 patients who had adenomas removed during participation in the study, after a median of 15.8 years, 1246 patients had died from any cause and 12 had died from colorectal cancer. Given an estimated 25.4 expected deaths from colorectal cancer in the general population, the standardized incidence-based mortality ratio was 0.47 (95% confidence interval [CI], 0.26 to 0.80) with colonoscopic polypectomy, suggesting a 53% reduction in mortality. Mortality from colorectal cancer was similar among patients with adenomas and those with nonadenomatous polyps during the first 10 years after polypectomy (relative risk, 1.2; 95% CI, 0.1 to 10.6). CONCLUSIONS These findings support the hypothesis that colonoscopic removal of adenomatous polyps prevents death from colorectal cancer. (Funded by the National Cancer Institute and others.)

The performance of colon polypectomy has proven to be one of the most impactful services provided by today's endoscopist. Advancements in instrumentation and endoscopic techniques have been studied intensely by endoscopists over the past decade in order to expand their extent of resection capabilities to large and complex polyps. Much of the research in the past year has focused on the safety and efficacy of performing endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and combined laparascopic-endoscopic resections (CLER). Experts have published case-series, multicenter studies, and even nationwide results on the use of these methods for complex polypectomy. Because of the novelty and increased risk of these procedures, recent research has also focused on the prevention, identification and management of complications related to polypectomy, particularly bleeding and perforation. This manuscript will review the recent literature addressing basic and advanced colon polypectomy techniques.

Barrett's epithelial dysplasia, the direct precursor to esophageal adenocarcinoma, is often unapparent and frequently missed during surveillance of Barrett's esophagus with four-quadrant forceps biopsy protocol.To determine whether the detection of dysplasia is improved by adding computer-assisted brush biopsy (EndoCDx©) to four-quadrant biopsy protocol.Patients with a history of Barrett's esophagus with dysplasia scheduled for endoscopic surveillance were recruited from four academic medical centers. Patients underwent brush biopsy followed by four-quadrant biopsy every 1-2 cm. The results from brush and forceps biopsy were reviewed independently by pathologists blinded to the other's results.Among 151 patients enrolled (124 men, 27 women; mean age: 65), 117 (77.5%) had forceps and brush-biopsy specimens adequate for interpretation. The mean number of forceps biopsies was 11.9 (median 10, range 2-40) and brush biopsies was 2.0 (median 2, range 1-4). The overall yield of forceps alone was 25.2% (n = 38). Brush biopsy added an additional 16 positive cases increasing the yield of dysplasia detection by 42% (95% CI: 20.7-72.7). The number needed to test (NNT) to detect one additional case of dysplasia was 9.4 (95% CI: 6.4-17.7). There were no significant differences in results among different centers, between standard versus jumbo forceps, or between forceps biopsies taken every 1 cm versus every 2 cm.These data suggest that computer-assisted brush biopsy is a useful adjunct to standard endoscopic surveillance regimens for the identification of dysplasia in Barrett's esophagus.

Colon screening examinations have been shown to discover neoplastic lesions at an early stage. Even the most careful studies by colonoscopy and by computed tomographic colonography (CTC) can overlook tumors with a diameter greater than 5 mm. Advances in technology have continually improved the ability to find polyps, which will lead to a real decrease in colorectal cancer incidence.

Background & Aims Patients with colitis have an increased risk of colorectal cancer, compared with persons without colitis. Many studies have shown chromoendoscopy (CE) to be superior to standard methods of detecting dysplasia in patients with colitis at index examination. We performed a prospective, longitudinal study to compare standard colonoscopy vs CE in detecting dysplasia in patients with inflammatory bowel diseases in a surveillance program. Methods We analyzed data from 68 patients (44 men, 24 women) diagnosed with ulcerative colitis (n = 55) or Crohn's disease (n = 13) at Mount Sinai Medical Center from September 2005 through October 2011. The patients were followed from June 2006 through October 2011 (median, 27.8 months); each patient was analyzed by random biopsy, targeted white light examination (WLE), and CE. Specimens were reviewed by a single blinded pathologist. The 3 methods were compared by using the generalized estimating equations method, and the odds ratios (ORs) for detection of dysplasia were calculated (primary outcome). Time to colectomy was analyzed by using the Cox model. Results In the 208 examinations conducted, 44 dysplastic lesions were identified in 24 patients; 6 were detected by random biopsy, 11 by WLE, and 27 by CE. Ten patients were referred for colectomy, and no carcinomas were found. At any time during the study period, CE (OR, 5.4; 95% confidence interval [CI], 2.9–9.9) and targeted WLE (OR, 2.3; 95% CI, 1.0–5.3) were more likely than random biopsy analysis to detect dysplasia. CE was superior to WLE (OR, 2.4; 95% CI, 1.4–4.0). Patients identified as positive for dysplasia were more likely to need colectomy (hazard ratio, 12.1; 95% CI, 3.2–46.2). Conclusions In a prospective study of 68 patients with inflammatory bowel diseases, CE was superior to random biopsy or WLE analyses in detecting dysplasia in patients with colitis during an almost 28-month period. A negative result from CE examination was the best indicator of a dysplasia-free outcome, whereas a positive result was associated with earlier referral for colectomy.

Advanced polypectomy includes the approach to large polyps, polyps that are difficult to access, and polyps that require special maneuvers for removal. Sessile polyps are considered difficult to remove, the larger diameters falling into the "very difficult" category, requiring advanced polypectomy techniques. Some pedunculated polyps may require advanced techniques. Most polyps in the colon are sessile, and many of these are located in the right colon, from the hepatic flexure to the cecal caput. Pedunculated polyps, with a pedicle of pulled-out mucosa and submucosa caused by the constant action of peristalsis in the colon's attempt to evacuate the polyp, usually are located in the sigmoid colon.

The flat adenoma may be a more aggressive pathway in colorectal carcinogenesis. Sessile adenomas from the National Polyp Study cohort were reclassified histopathologically as flat or polypoid and compared with initial and surveillance pathology.A total of 933 sessile adenomas detected during 1980-1990 were reclassified as follows: (1) adenoma thickness (AT):or =1.3 mm, and (2) adenoma ratio (AR): adenoma thickness2x normal mucosa thickness. Logistic regression was used to assess whether flat adenomas had an effect on risk for high-grade dysplasia initially, and a Cox proportional hazards model assessed the risk for advanced adenomas at surveillance.The analysis encompassed 8401 person-years of follow-up evaluation. AT and AR measures of adenoma flatness were 95% concordant. By the AT measure, flat adenomas (n = 474) represented 27% of all baseline adenomas. Flat adenomas were found to be no more likely to exhibit high-grade dysplasia than sessile (polypoid) or pedunculated adenomas, the odds ratio for high-grade dysplasia was 1.91 (95% confidence interval [CI], 0.66-5.47; P = 0.23) for sessile (polypoid) vs. flat adenomas and 1.78 (95% CI, 0.63-5.02; P = 0.28) for pedunculated vs. flat adenomas adjusted for size, villous component, and location, and corrected for correlation of risk within an individual patient. Patients with flat adenomas at initial colonoscopy were not at greater risk for advanced adenomas at surveillance compared with those with polypoid adenomas only, the odds ratio was 0.76 (95% CI, 0.4-1.42; P = .39), adjusted for multiplicity, age, and family history of colorectal cancer.Flat adenomas identified in the National Polyp Study cohort at baseline were not associated with a higher risk for high-grade dysplasia initially, or for advanced adenomas at surveillance.

Background: Endoscopic marking of intestinal lesions is essential when difficulty is anticipated with subsequent localization during surgical resection or postpolypectomy surveillance. The most commonly used indelible marker has been India ink, which must be diluted and sterilized, a cumbersome process. SPOT, a prepackaged, sterile Food and Drug Administration-approved formulation of pure carbon particles in suspension, eliminates the need for preinjection preparation. Methods: Ten patients with colonic polyps deemed endoscopically unresectable or malignant-appearing had the area surrounding the lesions injected with SPOT and subsequently underwent surgical resection. An additional 103 patients underwent colonoscopic injection with SPOT and were followed endoscopically or underwent surgery at another hospital. Results: The SPOT injection sites were visible to the surgeons in all 10 cases. On histopathologic evaluation, none of the resection specimens exhibited necrosis or abscess formation. In total, there were 118 SPOT injections in 113 patients; none had fever, abdominal pain, or any other signs or symptoms of inflammation develop. In the nonoperated group, 42 patients subsequently underwent colonoscopies at our institution, and in all cases stains were readily identifiable at the injection sites. Conclusions: SPOT is a safe and effective marker for use at colonoscopy when surgical resection is anticipated. It is also useful for endoscopic follow-up of patients who have not undergone surgery. (Gastrointest Endosc 2002;56:339-42.)

Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer

A small imaging capsule without cables, wires, or external connections has been developed for exploration of the small bowel. This swallowable device is propelled by peristalsis through the intestinal tract, and transmits data to a nearby receiver that captures video images on a regular basis. This technology will soon be available throughout the world, and it promises to revolutionize deep endoscopy of the small bowel. Sonde enteroscopy will be laid to rest forever. There continues to be considerable interest in the use of push enteroscopy in the investigation of obscure gastrointestinal bleeding. Physicians are beginning to rely more on intraoperative enteroscopy, because of its high degree of accuracy and its ability to provide visualization of the entire small bowel in selected patients in whom the bleeding source cannot be diagnosed, but who require blood transfusions.

Background: Residual adenoma is frequently found at the site of endoscopically resected large sessile adenomas on follow-up examination. We evaluated the efficacy of a thermal energy source, the argon plasma coagulator, to destroy visible residual adenoma after piecemeal resection of sessile polyps. Methods: Seventy-seven piecemeal polypectomies with or without the use of argon plasma coagulator were analyzed retrospectively. All polyps were sessile, 20 mm or greater in size. The results from three groups of patients were compared. The study group was composed of patients who had visible residual adenoma after piecemeal polypectomy and had the base of the polypectomy site treated with the argon plasma coagulator. The first comparison group consisted of patients who underwent standard piecemeal polypectomy in whom the colonoscopist thought that all adenomatous tissue was removed and no further treatment was necessary. The second comparison group included patients in whom visible residual adenoma was left at the base after piecemeal resection of large adenomas. Follow-up colonoscopy was performed approximately 6 months after the initial procedure to check for recurrent/residual adenomatous tissue. Results: The argon plasma coagulator was used after 30 piecemeal polypectomies in an attempt to eradicate visible residual adenomatous tissue; at follow-up, 50% of these cases had complete eradication of adenoma. The group in whom all visible tumor was removed by piecemeal polypectomy alone had an adenoma eradication rate of 54% on follow-up colonoscopy. In the patients in whom visible residual adenoma was left at the site the recurrence rate was 100% on the follow-up examination. Bleeding necessitating endoscopic therapy occurred once (3.3%) in the argon plasma coagulator group; there were four (12.5%) bleeding episodes and one (3.1%) confined retroperitoneal perforation in the complete piecemeal polypectomy group and no complications in the group in which polypectomy was incomplete. Conclusions: Argon plasma coagulator ablation of residual adenomatous tissue at the polypectomy base is safe and useful. It helps to complete the eradication of large sessile polyps when there is visible evidence of residual polyp. (Gastrointest Endosc 1999;49:731-5.)

Colonoscopy was introduced in the 1960s. The facility with which this technique is performed has been enhanced by vast improvements in instrumentation. In spite of this, physician attitudes concerning colonoscopy have changed little over the past several decades. The diet for precolonoscopic preparation has not been altered for 30 years. Colonoscopists have a great reluctance to use a new preparation instead of the 4 L electrolyte solution, perhaps because this was such a significant advance in colonoscopic cleansing, its predecessor being castor oil and enemas. Physicians continue to be wary of the patient who is taking acetylsalicylic acid in the absence of any studies that show that this is detrimental for polypectomy. The management of the patient on warfarin anticoagulation remains a subject for debate. As for antibiotic prophylaxis, most endoscopy units do not have a standardized approach, although there are good guidelines that, if followed, should decrease the risk of infective endocarditis. Sedation for the endoscopic examination is usually administered by the colonoscopist, although anesthesiologists may, in some countries (and in some defined areas of the United States) be the primary administrators of sedation and analgesia. The present article is a personal approach to the following issues: the preparation of the colon for an examination, current thoughts about anticoagulation and acetylsalicylic acid, antibiotic prophylaxis for colonoscopy and the technique for sedation out of the hospital.

An overview of the scientific literature on small-bowel enteroscopy demonstrates that sonde enteroscopy is becoming more and more limited in its indications. Push enteroscopy is now a well-accepted modality for evaluation of the patient with small-bowel disease, including those with undiagnosed causes for gastrointestinal bleeding, various types of malabsorption, and radiological abnormalities. Intraoperative enteroscopy has very specific indications, and there is a high rate of positive findings. It appears that an enterotomy with passage of a shorter, more maneuverable enteroscope is an acceptable way to evaluate the small bowel, although use of a sonde enteroscope may be an innovative method for intraoperative enteroscopy. In the evaluation of patients with iron-deficiency anemia or occult gastrointestinal bleeding in whom colonoscopy is negative, it is evidently more cost-effective to use a dedicated push enteroscope early on. The use of two different instruments--a gastroscope followed by a dedicated push enteroscope--is more expensive, and probably does not increase the yield for pathology. Many lesions that are responsible for obscure bleeding are actually located within reach of an upper intestinal endoscope, but are not recognized. This is probably due to inexperience on the part of the original endoscopist, who may see the pathology, but does not invoke it as the cause for bleeding. Outcome studies are now being performed, and there are some interesting considerations for combination hormonal therapy in patients with recurrent obscure bleeding, which most likely emanates from small-bowel arteriovenous malformations.

The need for standardized language is increasingly obvious, also within gastrointestinal endoscopy. A systematic approach to the description of endoscopic findings is vital for the development of a universal language, but systematic also means structured, and structure is inherently a challenge when presented as an alternative to the normal spoken word. The efforts leading to the "Minimal Standard Terminology" (MST) of gastrointestinal endoscopy offer a standardized model for description of endoscopic findings. With a combination of lesion descriptors and descriptor attributes, this system gives guidance to appropriate descriptions of lesions and also has a normative effect on endoscopists in training. The endoscopic report includes a number of items not related to findings per se, but to other aspects of the procedure, formal, technical, and medical. While the MST sought to formulate minimal lists for some of these aspects (e.g. indications), they are not all well suited for the inherent structure of the MST, and many are missing. Thus, the present paper offers a recommended standardization also of the administrative, technical, and other "peri-endoscopic" elements of the endoscopic report; important also are the numerous quality assurance initiatives presently emerging. Finally, the image documentation of endoscopic findings is becoming more obvious-and accessible. Thus, recommendations for normal procedures as well as for focal and diffuse pathology are presented. The recommendations are "minimal," meaning that expansions and subcategories will likely be needed in most centers. Still, with a stronger common grounds, communication within endoscopy will still benefit.

The value of performing comprehensive screening colonoscopy with complete colon polypectomy is widely accepted. Colon cancer is a significant cause of worldwide mortality and prospective studies have proven that colonoscopic polypectomy reduces both the incidence and mortality related to this disease. Over the past few decades the array of instruments and techniques have greatly expanded to assist with the safe endoscopic removal of colon polyps. This article will review the published literature regarding efficacy and safety of standard polypectomy techniques such as snare polypectomy, electrocautery, and endoscopic mucosal resection along with newer techniques such as endoscopic submucosal dissection and combined laparoscopic techniques.

Sixty-four patients took part in a cohort study measuring the efficacy of daily hormonal therapy in diminishing intestinal bleeding from small bowel angiodysplasia. Thirty patients received 5-10 mg norethynodrel either with mestranol, 0.075-0.15 mg (24 patients) or with conjugated estrogens, 0.625 mg (six patients). The cohort group consisted of 34 patients who either refused hormonal therapy (six patients) or were diagnosed early in our experience, before the resurgence of hormonal therapy (28 patients). Mean follow-up was 15.6 months (range 2-31 months) for the treated group and 13.4 months (range 1-23 months) for the untreated group. In addition, the change in monthly transfusion requirement with therapy was analyzed ("within group" analysis). Fifty percent (15 of 30) of the treated group required no further transfusion during therapy, while 44% (15 of 34) of the untreated group required no further therapy (not significant). During therapy, the mean monthly transfusion requirement of packed red blood cells in the treated group was not significantly different from that found before therapy (1.5 vs. 2.2 units, NS) or from that of the control group (1.5 vs. 1.6 units, NS). The findings do not support the use of hormonal therapy for bleeding from small intestinal angiodysplasia.

Colonoscopy may fail to detect neoplasia located on the proximal sides of haustral folds and flexures. The Third Eye Retroscope (TER) provides a simultaneous retrograde view that complements the forward view of a standard colonoscope.To evaluate the added benefit for polyp detection during colonoscopy of a retrograde-viewing device.Open-label, prospective, multicenter study evaluating colonoscopy by using a TER in combination with a standard colonoscope.Eight U.S. sites, including university medical centers, ambulatory surgery centers, a community hospital, and a physician's office.A total of 249 patients (age range 55-80 years) presenting for screening or surveillance colonoscopy.After cecal intubation, the disposable TER was inserted through the instrument channel of the colonoscope. During withdrawal, the forward and retrograde video images were observed simultaneously on a wide-screen monitor.The number and sizes of lesions (adenomas and all polyps) detected with the standard colonoscope and the number and sizes of lesions found only because they were first detected with the TER.In the 249 subjects, 257 polyps (including 136 adenomas) were identified with the colonoscope alone. The TER allowed detection of 34 additional polyps (a 13.2% increase; P.0001) including 15 additional adenomas (an 11.0% increase; P.0001). For lesions 6 mm or larger, the additional detection rates with the TER for all polyps and for adenomas were 18.2% and 25.0%, respectively. For lesions 10 mm or larger, the additional detection rates with the TER for all polyps and for adenomas were 30.8% and 33.3%, respectively. In 28 (11.2%) individuals, at least 1 additional polyp was found with the TER. In 8 (3.2%) patients, the polyp detected with the TER was the only one found. Every polyp that was detected with the TER was subsequently located with the colonoscope and removed. For all polyps and for adenomas, the additional detection rates for the TER were 9.7%/4.1% in the left colon (the splenic flexure to the rectum) and 16.5%/14.9% in the right colon (the cecum to the transverse colon), respectively.There was no randomization or comparison with a separate control group.A retrograde-viewing device revealed areas that were hidden from the forward-viewing colonoscope and allowed detection of 13.2% additional polyps, including 11.0% additional adenomas. Additional detection rates with the TER for adenomas 6 mm or larger and 10 mm or larger were 25.0% and 33.3%, respectively. (NCT00657371.).

Total colonoscopy can be difficult. It is recognized that abdominal pressure can be helpful in the performance of colonoscopy by externally splinting the endoscope to prevent loop formation. Properly applied abdominal pressure can limit patient discomfort and shorten examination time. Various techniques for abdominal pressure were studied in 201 consecutive patients who had total colonoscopy to the cecum. Abdominal pressure or change of body position was used 619 times in 165 patients (82%), with an average of 3.75 pressure applications per colonoscopy, most lasting less than 30 sec. Pressure was most commonly used when the endoscope tip was at the splenic flexure. Non-specific pressure to a region of the abdomen where looping developed, endoscopically observed specific pressure near the tip, and position change were used in a stepwise manner. Non-specific pressure was more successful in the left (78%) than in the right (47%) colon (p less than 0.0005). As intubation progressed left to right, specific pressure became more useful. When abdominal pressure was not useful, a change in patient position from left lateral to supine was successful in advancing the endoscope tip in 68% of patients.

Colonoscopic polypectomy continues to be a major activity of gastrointestinal endoscopists, based upon the belief that ridding the colon of polyps prevents colon cancer. We review recent literature bearing on this assumption, emphasizing the benefits and limitations of colonoscopy for screening and surveillance of polyps. CT colonography has developed as an alternative or adjunct to colonoscopy but has not surpassed it in accuracy or therapeutic potential. Other recent technologic developments, such as magnification and chromoendoscopy, are reviewed, and an attempt is made to put them in perspective.

Background Dysplasia-associated lesions or masses (DALMs) in inflammatory bowel disease (IBD) are a heterogeneous group of tumors with different natural histories. Objectives Our purpose was to determine the ability of gastroenterologists (GE) to distinguish adenoma-like (ALD) from non-adenoma-like DALMs (NALD) in patients with ulcerative colitis (UC) and to evaluate management practices with regard to these lesions. Participants Randomly chosen academic and private practice members of the American Society for Gastrointestinal Endoscopy and a group of IBD experts. Design All GEs answered a series of questions related to UC-associated DALMs and were asked to classify 13 digitally transmitted endoscopic images (5 ALD, 5 NALD, and 3 inflammatory polyps [IP]). Setting Internet-based survey. Patients Not applicable. Interventions Not applicable. Main Outcome Measurements Percentage of respondents who answered management questions and classified endoscopic images correctly. Results ALD, NALD, and IP were correctly diagnosed by 68%, 75%, and 82% of IBD experts; 58%, 56%, and 57% of academic gastroenterologists; and 60%, 73%, and 60% of private practice GEs, respectively. Overall, there were no significant differences in rates of correct diagnosis for the 3 types of polyps (P = .603). IBD experts showed a significantly higher correct diagnosis rate (P = .048) and interobserver agreement (P Limitations Only a single endoscopic image was used in this study. The response rate was 32%. Conclusion These data suggest that academic GEs and private practice GEs have more difficulty than IBD experts do in distinguishing between and managing DALMs in patients with UC.

Background The p53 tumor suppressor gene is commonly mutated in colorectal cancer. While the effect of p53 mutations on colorectal cancer prognosis has been heavily studied, less is known about how epidemiologic risk factors relate to p53 status, particularly in early colorectal neoplasia prior to clinically invasive colorectal cancer (including adenomas, carcinoma in situ (CIS), and intramucosal carcinoma). Methods We examined p53 status, as measured by protein overexpression, in 157 cases with early colorectal neoplasia selected from three New York City colonoscopy clinics. After collecting paraffin-embedded tissue blocks, immunohistochemistry was performed using an anti-p53 monoclonal mouse IgG2a [BP53-12-1] antibody. We analyzed whether p53 status was different for risk factors for colorectal neoplasia relative to a polyp-free control group (n = 508). Results p53 overexpression was found in 10.3%, 21.7%, and 34.9%, of adenomatous polyps, CIS, and intramucosal cases, respectively. Over 90% of the tumors with p53 overexpression were located in the distal colon and rectum. Heavy cigarette smoking (30+ years) was associated with cases not overexpressing p53 (OR = 1.8, 95% CI = 1.1–2.9) but not with those cases overexpressing p53 (OR = 1.0, 95% CI = 0.4–2.6). Heavy beer consumption (8+ bottles per week) was associated with cases overexpressing p53 (OR = 4.0, 95% CI = 1.3–12.0) but not with cases without p53 overexpression (OR = 1.6, 95% CI = 0.7–3.7). Conclusion Our findings that p53 overexpression in early colorectal neoplasia may be positively associated with alcohol intake and inversely associated with cigarette smoking are consistent with those of several studies of p53 expression and invasive cancer, and suggest that there may be relationships of smoking and alcohol with p53 early in the adenoma to carcinoma sequence.

This article discusses the important role endoscopy plays in the diagnosis and management of inflammatory bowel disease and how the procedure adds crucial information to the constellation of history, physical examination, radiographic findings, and laboratory values. Differentiation between Crohn's disease and ulcerative colitis has important ramifications for medical therapy, surgical options, and prognosis. This distinction can be accurately made in at least 85% of patients.

Colorectal cancer is an important cause of morbidity and mortality among Western nations, and is more common in the elderly than in younger individuals. With the general acceptance of the adenoma-carcinoma sequence, the current consideration is that colorectal cancer is preventable if all adenomas are removed before they have the chance to progress to cancer. To that end, physicians should now advocate screening for colorectal cancer and through this effort a large number of patients with adenomatous polyps will be discovered. It is important to understand the strategy in dealing with this growing population of patients with adenomas. After an initial polypectomy, patients with adenomas should be entered into a surveillance program to detect and remove recurrent adenomas. Recommended surveillance intervals are shorter for patients with a family history of colorectal cancer, those with multiple adenomas (2), large adenomas (or = 1cm), or those whose adenomas have high-grade dysplasia, villous architecture, or that are cancerous. Effective chemoprevention would be a potential method of lengthening colonoscopic surveillance intervals. Unfortunately, no treatment has been found to be effective enough to alter our current surveillance practice. The only recommendation that can be made at this time for those patients with a history of colonic adenomas is to add 3 g/day of calcium carbonate to their diet, though its effect on adenoma recurrence is modest.

Background: All colon polyps removed during colonoscopy should be recovered and submitted for histopathologic analysis. Published information is scant regarding techniques and devices for retrieval of polyps after polypectomy. The Roth Retrieval Net is a novel device that has been used to retrieve foreign bodies from the GI tract, but its use as a polyp retrieval device has not previously been described. Methods: A chart review was conducted over a 7-month period by one gastroenterologist in an office setting of all patients who had polyps retrieved after piecemeal polypectomy by using the Roth Retrieval Net. Results: All resected polyps were completely retrieved in a time-efficient manner. Histopathologic evaluation was not compromised by the use of this device. Conclusions: The Roth Retrieval Net is well suited for retrieval of multiple polyp fragments after colonoscopic polypectomy.

Although Ludlow1 in 1769 gave the first description of a pharyngo-esophageal diverticulum, it is named after Zenker who gave a precise pathologic description more than one century later2. Zenker’s diverticulum (ZD) is the commonest type of diverticulum in the upper gastro-esophageal tract. It is a herniation which usually arises in the posterior midline of the hypopharynx at a place where the muscular wall has weakened. The ZD is usually located just cranial to the upper esophageal sphincter (UES) of which the cricopharyngeal muscle is a part. However, a ZD can develop at any weak site of the muscular wall of the hypopharynx. Increased hypopharyngeal pressures during swallowing are probably important in the pathogenesis of the diverticulum3 4. The tissue bridge between the esophageal lumen and the pouch of the diverticulum is composed of mucosa, submucosa and fibrous tissue of varying thickness, and a muscular coat. In this tissue bridge the most voluminous and essential structure is the UES.

Nine consecutive patients in whom endoscopic management of delayed post-polypectomy hemorrhage was attempted are described. Each patient presented with active rectal bleeding 12 hours to 12 days after snare resection of a colon polyp. In each patient, repeat colonoscopy identified the bleeding site and various combinations of injection therapy, electrocautery, or thermal injury led to cessation of hemorrhage. No complications resulted from repeat colonoscopy and endoscopic therapy. Colonoscopy and endoscopic therapy is feasible, effective, and safe in selected patients with active delayed post-polypectomy hemorrhage.

Background: Two doses of sodium phosphate are recommended for colonic cleansing before colonoscopy. Patients need information about the onset and duration of activity of the preparation. This study was designed to develop practical prescribing information to patients to reduce anxiety concerning bowel accidents. Methods: Two hundred patients were requested to take a liquid diet the day before colonoscopy, to take 45 mL sodium phosphate with water or juice the evening before and the morning of the procedure, and to complete a questionnaire. Results: Bowel activity began 1.7 hours (range 0.5 to 13) after the first dose and continued for 4.6 (1 to 14) hours. For the second dose the time to onset was 0.7 hours (0.25 to 4), and bowel activity continued for 2.9 hours (0.5 to 6.5). Bowel activity was completed 4 hours after ingestion of the second dose in 83% of patients and within 5 hours in 87%. Three of 200 patients reported the need for bowel evacuation during transit. Conclusions: The activity from the second dose of sodium phosphate starts and ends sooner than that from the first dose. When advising patients on when to take the second dose of sodium phosphate, 4 hours for most and 5 hours for those with long commutes, should provide adequate time for almost all patients to avoid bowel activity during travel. (Gastrointest Endosc 1999;50:811-3.)