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The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of new or emerging endoscopic technologies that have the potential to have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent preclinical and clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. For this review, the MEDLINE database was searched through January 2011 using the keywords "bariatric," "endoscopic," "intragastric balloon," "duodenojejunal bypass sleeve," and "transoral gastroplasty." Reports on Emerging Technologies are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. These reports are scientific reviews provided solely for educational and informational purposes. Reports on Emerging Technologies are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment., (Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Although 140 colonoscopies is the recommended minimal requirement for gastroenterology fellows, it is unclear whether this minimum is a surrogate for competence., Objective: To assess whether 140 colonoscopies is an adequate threshold to determine > or =90% colonoscopy performance independence., Design: Retrospective analysis on a database constructed for quality control/improvement., Setting: Gastroenterology fellowship training program at a veterans hospital., Patients: Consecutive patients who underwent colonoscopy primarily for symptoms, previous polyps, or family history of cancer (a minority were performed for screening only) from April 2007 to September 2008. This study involved 11 gastroenterology fellows who performed 770 colonoscopies during 18 individual month-long rotations., Intervention: Assessment of various procedure-related parameters., Main Outcome Measurements: Determining when > or =90% independence in colonoscopy performance was reached., Results: Total colonoscopy time, time to cecal intubation, withdrawal time, and independent completion rates all significantly improved when first and third years of training were compared (P < .001 for all comparisons). The adenoma detection rate did not change between years of training. Independent completion was achieved in > or =90% of cases for all fellows after 500 colonoscopies, whereas no fellow reached a > or =90% independent colonoscopy completion rate after 140 colonoscopies., Limitations: Number of participants, single center., Conclusions: Becoming a competent colonoscopist requires repeated practice. Our study suggests that, although there is variability between a trainee's ability to become colonoscopy independent, 500 colonoscopies are likely required to ensure reliable (> or =90%) independent completion rates. Competency requires more than a single parameter.

Metastatic pancreatic adenocarcinoma presenting with immune thrombocytopenic purpura is a very rare association. To date, only 1 case report found in the literature delineates such an association. We present a case of a patient with newly diagnosed, biopsy-proven metastatic pancreatic adenocarcinoma with new-onset immune thrombocytopenic purpura. The patient's platelet count returned to normal limits after being treated with oral corticosteroid therapy. In conclusion, immune thrombocytopenic purpura can be associated with metastatic pancreatic adenocarcinoma and responds well to corticosteroid therapy.

Background: Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) can characterize and diagnose pancreatic lesions as malignant, but cannot definitively rule out the presence of malignancy. Outcome data regarding the length of follow-up in patients with negative or nondiagnostic EUS-FNA of pancreatic lesions are not well-established., Objective: To determine the long-term outcome and provide follow-up guidance for patients with negative EUS-FNA diagnosis of suspected pancreatic lesions based on imaging predictors., Methods: A retrospective review of patients undergoing EUS-FNA for suspected pancreatic lesions, but with negative or nondiagnostic FNA results was conducted at a tertiary care referral medical centre. Patient demographics, EUS imaging characteristics and follow-up data were examined., Results: Seventeen of 55 patients (30.9%) with negative/nondiagnostic FNA were subsequently diagnosed with pancreatic malignancy. The risk of cancer was significantly higher for patients who had associated lymph nodes on EUS (P<0.001) and vascular involvement on EUS (P=0.001). The mean time to diagnosis in the group with falsenegative EUS-FNA diagnosis was 66 days. The true-negative EUSFNA patients were followed for a mean of 403 days after negative EUS-FNA results without the development of malignancy., Conclusion: For patients undergoing EUS-FNA for a suspected pancreatic lesion, a negative or nondiagnostic FNA does not provide conclusive evidence for the absence of cancer. Patients for whom vascular invasion and lymphadenopathy are detected on EUS are more likely to have a true malignant lesion and should be followed closely. When a patient has been monitored for six months or more with no cancer being diagnosed, there appears to be much less chance that a pancreatic malignancy is present.

Background: The presence of gastroesophageal varices is considered a relative contraindication to performing transesophageal echocardiography (TEE), but this is based on expert opinion, and there is limited data to support this recommendation. The aim of this study was to review the complications and benefit of performing TEE in patients with known gastroesophageal varices., Methods: Fourteen patients with known esophageal varices who underwent TEE from 1997 to 2007 were identified. Patients' charts were reviewed for procedure-related complications as well as benefit in performing TEE., Results: The 14 patients had an average age of 50.4 years. Six patients had grade 2 esophageal varices at the time of TEE. The most common etiology of portal hypertension was alcoholic liver disease (11 of 14), and the most common indication for TEE was to rule out endocarditis (11 of 14). There were no major bleeding or other complications noted. All 14 procedures were able to provide the clinical information requested., Conclusion: Although the presence of known esophageal varices was previously thought to be a contraindication to performing TEE, the results of this study show that TEE without transgastric views can be performed without serious complications in patients with grade 1 or 2 esophageal varices who have not experienced recent variceal hemorrhages. Additionally, there is a definite benefit, as all of the clinical questions were successfully answered.

Bile duct stones and casts (BDS) after liver transplantation are associated with significant morbidity. Risk factors for BDS formation and the efficacy of treatment in liver transplant recipients have not been systematically studied. The aim of this study was to evaluate potential risk factors for the formation of BDS in patients post-liver transplant. A case-control study of consecutive liver transplant recipients at a university hospital from 1989 to 2007 was performed to identify risk factors for BDS formation. Cases included all liver transplant recipients with BDS, excluding those with concurrent t-tubes or biliary stents. Controls were chosen randomly from the total liver transplant population matched for year of transplantation. Pre- and post-OLT risk factors were analyzed with univariate and multivariate analyses. There were 49 cases and 101 controls over an 18-year-period (1289 liver transplants performed) with an incidence of 3.8% for BDS. In the cases, the median time to BDS diagnosis was 613 days from time of transplant. The controls had a median follow-up of 1530 days. Use of ursodeoxycholic acid was protective (P = 0.005), whereas bile duct pathology (P = 0.003), total cholesterol >/= 200 mg/dL (P = 0.008), and triglyceride >/= 150 mg/dL (P = 0.008) were significant risk factors for BDS formation. Endoscopic retrograde cholangiopancreatography (ERCP) was technically successful in all cases with resolution or improvement of liver chemistries in 59% (29) of patients. In conclusion, significant risk factors for forming BDS included bile duct pathology and elevated total cholesterol and triglyceride levels. Ursodeoxycholic acid had a significant effect in preventing the development of posttransplant BDS and should be used in those that are at increased risk. ERCP is a safe and effective diagnostic and therapeutic modality for these patients., ((c) 2008 AASLD.)

AL-Amyloid rarely presents in the gastrointestinal tract as acute gastrointestinal hemorrhage, especially in the absence of clinical disease elsewhere in the body. There are no reported cases of monoclonal gammopathy of undetermined significance progressing to AL-Amyloid presenting as lower gastrointestinal hemorrhage. We report a case of a patient initially diagnosed with monoclonal gammopathy of undetermined significance who progressed to AL-Amyloid over the course of 1 year. His progression resulted in primary colonic amyloidosis that manifested as lower gastrointestinal hemorrhage. The diagnosis was made by biopsy of a sigmoid plaque demonstrating necrotic material on histopathology. Amyloid deposition was seen on congo red and on birefringence. The bleeding stopped spontaneously without intervention and he was discharged his fourth day in the hospital. Further evaluation revealed no involvement in other organ systems. The plan is to treat with melphalan and dexamethasone. We conclude that early endoscopic examination and biopsy of the surrounding intestinal tissue is indicated when patients with monoclonal gammopathy of undetermined significance present with gastrointestinal hemorrhage to evaluate for the progression to AL-Amyloidosis. Treatment to prevent recurrent hemorrhage and further progression of the disease should be considered.

Objective: Reasons for failure to reach the cecum at optical colonoscopy are multifactorial. The purpose of this study was to compare CT colonography (CTC) findings in patients with complete versus those with incomplete optical colonoscopy., Materials and Methods: The clinical data and CTC examinations were reviewed in 100 patients who underwent CTC after incomplete optical colonoscopy. The findings were compared with a control group of 100 patients who underwent complete optical colonoscopy after CTC. The interactive 3D colon map and 2D multiplanar reconstruction images from CTC were reviewed independently by two experienced gastrointestinal radiologists for colorectal length (total, sigmoid colon, and transverse colon), number of acute angle flexures (reflecting tortuosity), and advanced diverticular disease. Discrepancies were resolved by secondary consensus review., Results: Significant differences existed between the complete and incomplete optical colonoscopy groups, respectively, for age (mean, 58.2 vs 63.4 years; p < 0.001), sex (60 men and 40 women vs 41 men and 59 women; p < 0.01), and prior abdominal surgery (26.0% vs 48.0%; p < 0.01). Significant differences were seen between the complete and incomplete optical colonoscopy groups, respectively, for all the CTC factors that were evaluated: total colorectal length (mean, 167.0 vs 210.8 cm; p < 0.0001), sigmoid colon length (mean, 48.7 vs 66.8 cm; p < 0.0001), transverse colon length (mean, 49.2 vs 66.3 cm; p < 0.0001), number of flexures (mean, 9.6 vs 11.9; p < 0.0001), and advanced diverticular disease (22.0% vs 34.0%; p <0.05)., Conclusion: Anatomic features associated with failure to reach the cecum at optical colonoscopy included colonic elongation, tortuosity, and advanced diverticular disease. These predictive factors may have implications for optical colonoscopy training and performance and for patients sent to optical colonoscopy for polyps prospectively detected at CTC.

Background: Capsule endoscopy performed via the traditional peroral route is technically challenging in patients with dysphagia, gastroparesis, and/or abnormal upper-GI (UGI) anatomy., Objective: To describe the indications and outcomes of cases in which the AdvanCE capsule endoscope delivery device, which has recently been cleared by the Food and Drug Administration, was used., Design: Retrospective, descriptive, case series., Setting: Tertiary care, university hospital., Patients: We report a case series of 16 consecutive patients in whom the AdvanCE delivery device was used. The study period was May 2005 through July 2006., Interventions: Endoscopic delivery of the video capsule to the proximal small bowel by using the AdvanCE delivery device., Main Outcome Measurements: Indications, technique, and completeness of small bowel imaging in patients who underwent endoscopic video capsule delivery., Results: The AdvanCE delivery device was used in 16 patients ranging in age from 3 to 74 years. The primary indications for endoscopic delivery included inability to swallow the capsule (10), altered UGI anatomy (4), and gastroparesis (2). Of the 4 patients with altered UGI anatomy, 3 had dual intestinal loop anatomy (ie, Bilroth-II procedure, Whipple surgery, Roux-en-Y gastric bypass) and 1 had a failed Nissen fundoplication. In all cases, the capsule was easily deployed without complication, and complete small intestinal imaging was achieved., Limitations: Small patient size., Conclusions: Endoscopic placement of the Given PillCam by use of the AdvanCE delivery device was safe and easily performed in patients for whom capsule endoscopy would otherwise have been contraindicated or technically challenging.

Background: EUS, CT, and positron emission tomography (PET) have all been used in the preoperative staging of esophageal cancer separately or in various combinations., Objective: Our purpose was to determine the value and role of EUS when used in conjunction with CT and PET imaging in staging cancer of the esophagus and gastroesophageal junction., Design: Retrospective single-center clinical trial., Setting: Academic tertiary care center., Patients: Data were examined for 56 patients who concomitantly underwent examination with EUS, CT, and PET in a multimodality staging program., Main Outcome Measurements: EUS, CT, and PET were examined for their ability to detect the primary tumor, local tumor stage, locoregional adenopathy, and distant metastases. With use of surgical resection as baseline therapy, the frequency at which EUS, CT, and PET affected and changed management was examined., Results: EUS is the only imaging test that identified all primary tumors and provided tumor staging. EUS identified a significantly greater number of patients (58.9%) with locoregional nodes than did CT (26.8%), P = .0006, or PET (37.5%), P = .02. CT identified 14.3% and PET identified 26.8% of patients with distant metastases. With CT alone, 15.2% of patients were not taken to surgery, whereas PET affected management by preventing surgery because of metastatic disease in 28.3% of patients. EUS changed management by guiding the need for neoadjuvant therapy in 34.8% of patients., Limitations: Retrospective study, nonblinded study, lack of pathologic reference standard., Conclusion: The primary strength of EUS in a multimodality staging strategy is in identifying patients with locally advanced disease and guiding the need for preoperative neoadjuvant therapy. EUS is not suited to determine resectability of esophageal cancer alone and thus is most effective when used in conjunction with other imaging tests such as CT and PET.

Context: Pancreatitis is the most frequent complication of endoscopic retrograde cholangiopancreatography. Controversy exists whether low osmolarity non-ionic contrast agents lessen the rate of pancreatitis and pancreatic injury. To evaluate we used a canine model to compare pancreatography performed with ionic and non-ionic contrast., Design: Dogs were anesthetized and underwent open transduodenal cannulation of the main pancreatic duct under fluoroscopic control until complete acinarization was achieved to maximize injury. Three dogs received diatrozate, an ionic contrast agent with osmolarity of 1,415 mosM and three dogs were injected with omnipaque a non-ionic agent with osmolarity of 672 mosM., Main Outcome Measures: Serial amylase and white cell counts were followed for 48 hours at which time dogs were sacrificed. Each pancreas was then examined for evidence of pancreatitis and cellular injury with both light and electron microscopy., Results: All animals developed significant hyperamylasemia and elevated white blood cell counts, without significant difference in the mean peak amylase (10,721 U/L vs. 9,367 U/L, P=0.876) or white cell counts (25.8 k/mL vs. 24.1 k/mL, P=0.586) between the ionic and non-ionic contrast groups. Light microscopy showed no evidence of pancreatitis in either group of dogs. Electron microscopy showed cellular injury of the ductal cells in two dogs injected with non-ionic contrast., Conclusion: In a pancreatic canine model, low osmolarity, non-ionic contrast does not appear to lessen cellular injury.

Background: In patients who develop symptoms after Nissen fundoplication, the precise mechanism of failure can be difficult to determine. Current testing modalities do not demonstrate sufficient anatomic detail to definitively determine the mechanism. This observational study establishes that EUS can determine fundoplication integrity and hiatal anatomic relationships after Nissen fundoplication., Methods: EUS was performed on the native esophagogastric junction and after Nissen fundoplication in two swine. The EUS characteristics of a properly performed fundoplication were determined. Subsequently, complications of Nissen fundoplication were created, and EUS was performed on each. The EUS criteria of each mechanism of failure were defined., Results: EUS provided sufficient axial resolution to distinguish the esophagus, the fundoplication, and the surrounding hiatal structures within a single image. US of the native esophagogastric junction discerned the length of intra-abdominal esophagus, esophagogastric junction, crura, and anterior hiatus, and, thus, the point of entry into the abdominal cavity. EUS of Nissen fundoplication revealed a 5-layered pattern in a 360 degree configuration. These layers represent the following: (1) the esophageal wall, (2) the space between the esophagus and the fundoplication, (3) the inner gastric wall of the fundoplication, (4) the gastric lumen, and (5) the outer gastric wall of the fundoplication. A slipped repair was identified by the presence of an echogenic gastric serosa within the fundoplication. A tight fundoplication results in attenuation of the gastric walls, thickening of the esophageal wall, and loss of the 5-layer pattern secondary to obliteration of the potential spaces of the gastric lumen. Dehiscence of the fundoplication was evidenced by a less than 360 degree 5-layer pattern., Conclusions: EUS of hiatal anatomic relationships is feasible and provides detailed information regarding the integrity and the position of a Nissen fundoplication. EUS may enable a precise determination of the anatomic causes of failure after antireflux surgery.

Objectives: Acute nonvariceal upper gastrointestinal (GI) bleeding is the most common medical emergency encountered by gastroenterologists resulting in high patient morbidity and cost. We sought to establish if a GI bleeding clinical care pathway could improve the quality and cost effectiveness of inpatient medical care., Methods: A disease management program for acute upper GI bleeding was established. Length of stay, time to endoscopy, utilization of potentially unnecessary radiological tests, acid suppression, and cost of care were compared between patients pre- and postinitiation of GI bleeding pathway guidelines., Results: The instituted GI bleeding management program significantly reduced the use of intravenous H2-blockade from 65.3% to 47.7% (p = 0.002). The use of radiological tests, time to endoscopy, and length of hospital of stay were unchanged. There was a trend toward a reduction in total cost and variable direct cost per patient admitted with acute upper GI bleeding, from $5,381 to $4,627 and from $2,269 to $1,952, respectively., Conclusion: A clinical care pathway may affect the management of acute upper GI bleeding and reduce costs. However, there are significant limitations and barriers to the overall effectiveness of such a pathway in actual clinical practice.

After orthotopic liver transplantation (OLT), biliary duct complications can occur in as many as 10% to 35% of patients. In the early medical and surgical literature, surgical therapy was the primary mode of management of biliary tract complications and was the eventual course of operative intervention in up to 70% of cases. However, with recent advances in therapeutic biliary endoscopy, the current endoscopic and transplantation literature suggests that endoscopic management with techniques such as endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy, biliary stenting, and stone removal techniques can be successfully applied for the majority of post-OLT biliary complications. The most common biliary complications after OLT include biliary strictures (anastomotic and nonanastomotic); bile duct leaks, common bile duct stones, and biliary casts; sphincter of Oddi/ampullary muscle dysfunction/spasm; and disease recurrence (eg, primary sclerosing cholangitis). Predisposing factors for biliary complications after OLT include hepatic artery thrombosis, impaired perfusion of the biliary tree, portal vein thrombosis, and preservation or harvesting injuries, which can increase the incidence of complications as much as 40%. Use of immunosuppressive agents such as cyclosporine can lead to cholesterol/bile stasis and stone formation. Outside of endoscopic therapy, there is little medical or dietary management that can be applied for post-OLT biliary complications. Ursodiol (ursodeoxycholic acid) has often been used as a neoadjuvant to ERCP therapy in the setting of common bile duct stones/casts, and low-fat diets may be recommended in this setting, but no large, randomized trials have advocated medical or conservative management alone.

Background: Endoscopic optical coherence tomography provides images of the GI mucosa and submucosa in microscopic detail. It is unknown whether endoscopic optical coherence tomography can reliably detect dysplasia. Colon polyps were used as a model to determine whether dysplasia in GI tissue has characteristic optical coherence tomography imaging features., Methods: Endoscopic optical coherence tomography images of colon polyps and normal colon tissue were obtained at colonoscopy. In real time, endoscopists compared tissue organization and light scattering for polyps and normal mucosa with endoscopic optical coherence tomography. Imaged polyps were removed and evaluated histopathologically. Organization and light scattering, as assessed by endoscopic optical coherence tomography at colonoscopy, were compared for adenomas versus hyperplastic polyps. A computer program also quantified and compared the degree of light scattering for hyperplastic polyps and adenomas., Results: A total of 44 polyps were imaged in 24 patients (30 adenomas, 14 hyperplastic polyps). Endoscopic optical coherence tomography images of adenomas had significantly less structure (p = 0.0005) and scattered light to a lesser degree than hyperplastic polyps (p = 0.0007). Hyperplastic polyps were significantly closer in organization (p = 0.0003) and light scattering (p = 0.0006) to normal mucosa as compared with adenomas. By digital image analysis, the light-scattering property of hyperplastic polyps was closer to normal mucosa compared with adenomas (14.86 vs. 45.81; p = 0.0001)., Conclusions: Real-time endoscopic optical coherence tomography imaging differentiated adenomas, hyperplastic polyps, and normal colon tissue. By using the colon adenoma as a model, the endoscopic optical coherence tomography characteristics of dysplasia are loss of tissue organization and reduced light scattering.