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Aliment Pharmacol Ther 2010; 32: 1145–1153 Summary Background Colon capsule endoscopy (CCE) is a new, non-invasive technology. Aim To conduct a prospective, multicentre trial to compare CCE and colonoscopy in asymptomatic subjects enrolled in screening or surveillance programmes for the detection of colorectal neoplasia. Methods Patients underwent CCE on day one and colonoscopy (gold standard) on day two. CCE and colonoscopy were performed by independent endoscopists. Results A total of 545 patients were recruited. CCE was safe and well-tolerated. Colon cleanliness was excellent or good in 52% of cases at CCE. Five patients with cancer were detected by colonoscopy, of whom two were missed by CCE. CCE accuracy for the detection of polyps ≥6 mm was 39% (95% CI 30–48) for sensitivity, 88% (95% CI 85–91) for specificity, 47% (95% CI 37–57) for positive predictive value and 85% (95% CI 82–88) for negative predictive value. CCE accuracy was better for the detection of advanced adenoma, in patients with good or excellent cleanliness and after re-interpretation of the CCE videos by an independent expert panel. Conclusions Although well-tolerated, CCE cannot replace colonoscopy as a first line investigation for screening and surveillance of patients at risk of cancer. Further studies should pay attention to colonic preparation (Clinicaltrial.gov number NCT00436514).

Background NOTES has changed the working environment of endoscopy, leading to new difficulties. The limitations of conventional endoscopes call for the development of new platforms. Robotics may be the answer. Materials and methods The authors compared human to robotized manipulation of a flexible endoscope into the abdominal cavity, in an animal model. Thirty-two participants were enrolled. Results were analyzed according to the clinical background of the participants: experienced endoscopists, experienced laparoscopists, and medical students. Two single-channel gastroscopes were used. Whereas one was not modified, the other had the handling wheels replaced by motors controlled through a computer and a joystick. A NOTES transgastric approach was used to access the peritoneal cavity. The time to touch previously positioned intra-abdominal numbered plastic targets was recorded 3 times with each endoscope. Results Mean time to complete the tasks was significantly shorter using the conventional endoscope (2.71 vs 6.96 minutes, P < .001). When the robotized endoscope was used, the mean times of endoscopists (7.42 minutes), laparoscopists (6.84 minutes), and students (6.77 minutes) were statistically identical. No differences were found between laparoscopists and students in both techniques. Discussion Applying robotics to a flexible endoscope fails to enhance ability to move into the abdominal cavity, partly because of the interface. To overcome the limitations of endoscope when performing complex NOTES tasks, robotics may be useful, especially to control the instruments and to stabilize the endoscope itself. Conclusion Robotized endoscope with joystick interface is not sufficient to enhance immediate intuitiveness of flexible endoscopy applied to NOTES.

Background Endoscopic submucosal dissection (ESD) is proving to be effective for the resection of selected early gastric and colon cancers. Its application and appropriateness could be extended if a means of determining lymphatic dissemination without recourse to a conventional operation could be provided. Objective To demonstrate the feasibility of companion sentinel node biopsy (SNB) by natural orifice transluminal endoscopic surgery (NOTES) concurrent with intraluminal ESD in both the sigmoid colon and stomach. Design Acute porcine model. Intervention Arbitrarily selected mucosal foci were targeted for combined NOTES-SNB and ESD in the sigmoid and stomach of 2 separate anesthetized animals. NOTES peritoneal access was obtained either transgastrically or transvaginally. A second intraluminal endoscope was passed either orally or rectally, as appropriate, to perform submucosal injection for lymphatic mapping under direct vision of the NOTES endoscope. This endoscope then identified the first-order draining (sentinel) nodes and allowed their excisional biopsy. The sigmoid was retracted by magnetic assistance as required, while torque of an intraluminal gastroscope manipulated the stomach. After retrieval of the nodes, 1-cm and 1.5-cm specimens were resected from the sigmoid and stomach, respectively, by conventional ESD. At procedure end, necropsy was performed. Results All sentinel nodes were identified, underwent biopsy, and were retrieved intact. ESD was subsequently readily performed without complication. SNB completeness and ESD quality were confirmed postprocedure. Limitations Experimental model with limited sample size. Conclusions Although not yet appropriate for human use, this proposal merits serious consideration as a potential means of augmenting the effectiveness and appropriateness of ESD techniques for GI neoplasia.

Few data are available concerning the long-term outcome of patients treated endoscopically for bleeding small-bowel vascular lesions (SBVL). The aim of this study was to evaluate the risk of rebleeding after endoscopic therapy for SBVLs detected by video capsule enteroscopy (VCE). The secondary aim was to assess risk factors for rebleeding.A prospective, multicenter study (15 centers) was conducted, involving patients with obscure gastrointestinal bleeding and SBVL on VCE who were treated during double-balloon enteroscopy (DBE). The likelihood of bleeding was defined according to VCE findings, as high or low.A total of 183 patients underwent endotherapy during DBE, and 64 (35 %) had rebleeding during the 1 year follow-up period. Multivariate analysis indicated that cardiac disease (hazard ratio [HR] 2.04, 95 % confidence interval [CI] 1.20 - 3.48; P 0.01) and the presence of overt bleeding (HR 1.78, 95 %CI 1.07 - 2.97; P = 0.03) at presentation were associated with the risk of rebleeding. The association between chronic renal failure and the risk of rebleeding was close to statistical significance (HR 1.77, 95 %CI 0.94 - 3.33; P = 0.08). Kaplan-Meier analysis suggested that patients treated during DBE for a lesion with low likelihood of bleeding on VCE had higher rebleeding rates than those with a high likelihood of bleeding (HR 1.87, 95 %CI 0.94 - 3.37; P = 0.07).Despite long-term remission in most patients, about one-third had rebleeding at 1 year. Independent risk factors for rebleeding were cardiac disease and overt bleeding at original presentation. The lesion characteristics on VCE may be useful to evaluate the bleeding potential of the lesion and may be used for better selection of patients for DBE.

Stent-In-Stent Insertion Using Argon Plasma Coagulation for the Cannulation of Multiple Malfunctioning Biliary Noncovered Self-Expandable Metal Stents

Some esophageal strictures resist endoscopic treatments. There is a need for new treatments, such as specifically designed stents.Our study sought to compare the results achieved with a standard, fully covered metallic stent (FCMS) and those achieved using a stent designed specifically for benign strictures (BS-FCMS).The study used a prospective, multicenter, controlled design, with patients recruited from tertiary referral centers. Patients with refractory esophageal strictures were included. Standard FCMS were used in group 1 (N = 24), and BS-FCMS were used in group 2 (N = 17). Patients were followed for 24 months after stent removal. The main outcomes measured were stricture resolution rate, 24 months' recurrence rate and stent-related morbidity.Early stent migrations occurred in one (4.1%) patient from group 1 and five (29.4%) from group 2 (p 0.05). During esophageal stenting, complications occurred in six patients (25%) in group 1 and six patients (35.3%) in group 2 (p = 0.47), respectively. Fifty percent of complications were attributed to migration. There was no procedure-related morbidity associated with the extraction of the stent. The stricture resolution rate was, respectively, 95.2% in group 1 and 87.5% in group 2 (the difference between the two groups is not significant). During follow-up, stricture recurrence occurred in 15/19 patients (group 1, 79%) and 7/8 patients (group 2, 87.5%; p = 1.0). The median time to recurrence of esophageal stricture was 1.7 months (group 1, 0.6-12 months) and 1 month (group 2, 0.1-6 months). Study limitations include its nonrandomized design.The stricture resolution rate was high at the end of the stenting period for both types of stents without any statistical difference between the two groups, but the long-term results were disappointing, with stricture recurring frequently and rapidly in both groups.

To the best of our knowledge, this is the first report of the application of hemostatic forceps in active gastrointestinal (GI) bleeding that is not related to endoscopic submucosal dissection. An 86-year-old woman with chronic intake of low-dose aspirin had a Dieulafoy’s lesion of the third duodenal portion. Bleeding control with epinephrine injection was unsuccessful. A 60-year-old man presented with a bleeding ulcer in the duodenal bulb. Ten days after combined endotherapy, he had recurrent bleeding from two minimal lesions in the same location. A 66-year-old woman under combined antithrombotic treatment was referred to us for chronic GI bleeding of unexplained origin. Endoscopy revealed active diverticular bleeding in the second duodenal portion. A 61-year-old woman underwent endoscopic mucosal resection of superficial gastric adenocarcinoma, which was complicated with immediate bleeding. In all cases, the blood was washed out using a water-jet-equipped, single-channel gastroscope with a large working channel. The bleeding points were pinched and retracted with hemostatic forceps. Monopolar electrocoagulation was performed using an electrosurgical current generator. Hemostasis was achieved. No complications occurred. In conclusion, hemostatic forceps may be an effective as well as safe alternative approach for active GI bleeding of various origins.

Background Esophageal duplication is a rare congenital lesion. Surgery is the standard treatment. Tubular duplication is extremely rare, with esophageal communication in very few cases. Objective The aim of this study was to document the feasibility of the endoscopic management of tubular esophageal duplication. Design Case report. Intervention A 14-year-old boy presented with acute dysphagia and acute retrosternal pain. Based on his radiographic and endoscopic findings, a cystic esophageal duplication with an upper esophageal stricture was initially suspected. A laparoscopic gastrostomy was performed. A cyst resection through right thoracoscopy assisted by flexible endoscopy was decided upon. When no extraluminal cystic duplication was found, a tubular duplication was considered and the procedure was abandoned. An endoscopic treatment was performed. A standard endoscope was inserted through an upper esophageal stricture. Two lumens were identified 25 cm from the incisors. A pediatric endoscope was passed through the main one, revealing a thick intraluminal bridge. By using a guidewire, the endoscope's passage into the narrow lumen revealed a distal communication with the esophagus. With the guidewire left in place, the endoscope was reintroduced into the main lumen. A lengthwise incision of the bridge was performed by using a needle knife. At the end of the procedure, an esophageal dilation was performed. Histology confirmed the diagnosis of duplication. Results The endoscopic incision of the duplication was completed uneventfully. For 11 months, the patient followed a normal diet and experienced no symptoms. Limitations Single case. Conclusion To our knowledge, this is the first report of successful endoscopic incision of a total tubular esophageal duplication.

Beyond doubt, laparoscopic cholecystectomy has changed the focus of surgery and the mind-set of nearly all surgeons. For this reason, the initial natural orifices translumenal endoscopic surgery (NOTES) project focused on cholecystectomy, which seemed to be the most logical and appealing clinical application. The first reports on cholecystectomy confirmed the feasibility of NOTES but identified substantial technical limits because of exposure, endoscope stability issues, and limitations in the control of dissection tools [1, 2]. These limitations led to experimentation with other natural orifice accesses: the colon, the urinary bladder, and combined routes [3, 4]. Although transcolonic cholecystectomy has been reported in survival studies, to date, the feasibility of transgastric cholecystectomy has been described only in nonsurvival animal models [1, 2, 5]. We report the successful performance of transgastric cholecystectomy with survival in a porcine model.

The systematic use of metal stents to treat biliary obstruction is restricted by high cost compared with plastic stents. The aims of this study were to compare cost and efficacy of plastic stents and metal stents in the treatment of patients with malignant common bile duct strictures and to define factors that predict survival of these patients.One hundred eighteen patients (mean age 75 years) with malignant strictures of the common bile duct were randomized to placement of a plastic stent or metal stent. Comparisons were made with the Mann-Whitney or chi-square test as indicated; survival rates were compared with a Cox proportional hazards model.There was no significant difference in survival between the two groups. Time to first obstruction was longer for patients in the metal stent group (metal stent, median not reached vs. plastic stent, 5 months; p = 0.007). The number of additional days of hospitalization, days of antibiotic therapy, and the numbers of ERCPs and transabdominal US procedures was significantly higher in the plastic stent group. After multivariate analysis, only the presence of liver metastases was independently related to survival (p0.0005; OR = 2.25). This variable defined a group with a shorter survival. Median survival of patients with hepatic metastasis at diagnosis was 2.7 months compared with 5.3 months for patients without liver metastasis; in the latter group, the overall cost associated with metal stents was lower than for plastic stents.Metal stent placement is the most effective treatment of inoperable malignant common bile duct stricture. Placement of a metal stent is cost effective in patients without hepatic metastases, whereas a plastic stent should be placed in patients with spread of the tumor to the liver.

Type 1 hepatorenal syndrome (HRS) is a severe complication of cirrhosis associated with a short median survival time (2 weeks). Although the administration of terlipressin improves renal function, its effect on survival is unknown. This study investigated predictive factors of survival in patients with type 1 HRS treated with terlipressin.Ninety-nine patients with type 1 HRS treated with terlipressin in 24 centers were retrospectively studied. Terlipressin-induced improved renal function was defined as a decrease in serum creatinine value to130 micromol/L or a decrease of at least 20% at the end of treatment.At inclusion, the Child-Pugh score was 11.8 +/- 1.6 (mean +/- SD). Terlipressin (3.2 +/- 1.3 mg/day) was administered for 11 +/- 12 days. Renal function improved in 58% of patients (serum creatinine decreased by 46% +/- 17% from 272 +/- 114 micromol/L). Median survival time was 21 days. Survival rate was 40% at 1 month. Multivariate analysis showed that improved renal function and Child-Pugh scoreor =11 at inclusion were independent predictive factors of survival (P0.0001 and 0.02, respectively). Thirteen patients underwent liver transplantation (92 +/- 95 days after HRS onset), 10 of whom had received terlipressin and had had improved renal function.This retrospective uncontrolled study shows that in patients with type 1 HRS, terlipressin-induced improved renal function is associated with an increase in survival. Thus, a randomized trial investigating the effect of terlipressin on survival in patients with type 1 HRS should be performed.

Diffuse Large B-Cell Lymphoma Complicated With Jejunal Stricture: The Palliative Role of Double-Balloon Enteroscopy

Esophageal Stent Occlusion From A Gastrostomy Tube: Balloon Dilator—Assisted Endoscopic Management

Hypothesis Natural orifice transluminal endoscopic surgery (NOTES) provides the potential for performance of incisionless operations. This would break the physical barrier between bodily trauma and surgery, representing an epical revolution in surgery. Our group at IRCAD-EITS (Institut de Recherche contre les Cancers de l’Appareil Digestif [Institute of Digestive Cancer Research]–European Institute of TeleSurgery) has been actively involved in the development of NOTES since 2004 with a dedicated project created to develop feasibility and survival studies and new endoscopic technology. Design NOTES cholecystectomy in a woman via a transvaginal approach. Setting University hospital. Patient The patient was a 30-year-old woman with symptomatic cholelithiasis. Intervention The procedure was carried out by a multidisciplinary team using a standard double-channel flexible videogastroscope and standard endoscopic instruments. The placement of a 2-mm needle port, mandatory to insufflate carbon dioxide and to monitor the pneumoperitoneum, was helpful for further retraction of the gallbladder. At no stage of the procedure was there need for laparoscopic assistance. All of the principles of cholecystectomy were strictly adhered to. Results The postoperative course was uneventful. The patient had no postoperative pain and no scars, and was discharged on the second postoperative day. Conclusions Transluminal surgery is feasible and safe. NOTES, a radical shift in the practice and philosophy of interventional treatment, is becoming established and is enormously advantageous to the patient. With its invisible mending and tremendous potential, NOTES might be the next surgical evolution.

Self Expending Metallic Stents (SEMS) with Antireflux Valve for Distal Esophageal Carcinoma: Results of a Randomized Trial Marc Le Rhun, Emmanuel Ben Soussan, Emmanuel Coron, Anne Le Sidaner, Thierry Barrioz, Dimitri Coumaros, Jean-Michel Nguyen, Bertrand Vedrenne, Philippe Bichard, Christian Boustiere, Frederic Prat D’Endoscopie Digestive Societe Francaise Aims: SEMS are commonly used in the palliation of dysphagia in patients with inoperable esophageal carcinoma. However they predispose to gastroesophageal reflux when deployed across the gastroesophageal junction. The aims of this study were 1) to assess the influence of the antireflux valve on trans-prothetic reflux (primary outcome) and 2) to compare the results of SEMS with and without antireflux valve in terms of reflux symptoms, quality of life (QOL), improvement of dysphagia and complications (secondary outcomes). Patients and Methods: Thirty eight patients (age 71 G 12 years ; sex ratio 5) with malignant strictures of the distal esophagus or gastric cardia (53% adenocarcinomas) were enrolled in 9 centers. Carcinomas were locally advanced (47%) or generalized. After randomization, patients received either a covered SEMS without antireflux valve (CHOOSTENT , Life Europe) associated to standard PPI therapy and postural advice (n Z 19) or a similar type of SEMS including an antireflux device (DOSTENT , Life Europe) (n Z 19). Trans-prosthetic reflux was assessed at day 2 using a radiological score based on barium esophagography performed after Trendelenburg maneuver and graded from 0 (no reflux) to 12 (maximum). Monthly telephone interviews were conducted for: a) OMS scoring from 0 (excellent) to 5 (poor) b) QOL assessment (based on the Reflux-Qual Simplifie scoring system) from 0 (poor) to 100 (excellent) c) dysphagia scoring from 0 (no dysphagia) to 5 (complete dysphagia) and d) regurgitation scoring from 0 (no regurgitation) to 16 (maximum). Results :No difference was noted in terms of age, sex, size of lesion, prosthesis length (12 G 2.5 cm) and need for dilation (30%) prior to SEMS placement. No difficulty to place SEMS nor complication were noted. QOL and dysphagia were improved in both groups. Mean survival was similar in both groups (180 days). Results according to the type of SEMS were as follows: (table 1) Conclusions: These two types of SEMS are equally effective on the palliation of dysphagia and improvement of QOL. However, SEMS with antireflux valve are more efficient to prevent trans-prosthetic gastroesophageal reflux but at the cost of an increased likehood of migrations.

Diagnostic Value of Capsule Endoscopy (CE) in Obscure Digestive Bleeding (ODB) and Effect of Erythromycin Injection Dimitri Coumaros, Laurent Claudel, Patrick Levy, Michel Doffoel Aims : Evaluate the diagnostic yield of CE in ODB and the effect of erythomycin injection. Patients andmethods: In this prospective randomized study, 37 patients (pts) (mean age : 61 years) with an occult (n = 19) or overt (n = 18) ODB, were investigated by the Given M2A capsule, with (n = 19) or without (n = 18) intravenous injection of 3 mg/kg erythomycin, 30 to 60 min before CE. Colonic cleansing with 4 L PEG (n= 34) or 2 bottles of sodium phosphate (n = 3) ending 1 h before CE was undertaken. Lesions were classified according to their bleeding potential : nil (L0), probable (L1) or certain (L2) if an active bleedingwas visible. A single diagnosis per patient was delivered. Diagnostic agreement coefficient between a senior and a junior endoscopist was calculated based on 21 examinations. Gastric and small bowel transit times as well as the possibility of visualizing the colon were compared between the 2 groups. The duration of video analysis was measured. Results : 36 examinations out of 40 were valid (3 technical failures, 1 prolonged retention in the lower esophagus). The examination of 3 pts was repeated. 72 lesions L1 and 2 L2 were detected in 30 pts (83%). These pts had one type of lesion (n = 11), 2 (n = 15) or 3 types of different lesion (n = 4). The resulting diagnosis was angiectasias (n = 14), ulcerations (n = 7), red spots (n = 5), varix (n= 1), tumor (n= 1), nematodes (n= 1), polypoid angiectasia (n= 1). The location of these lesions was jejuno-ileal (n = 23), duodenal (n = 3), gastric (n = 1), colonic (n = 1) or multifocal (n = 2). The interobserver kappa coefficient was 0.64. The presence of red spots was linked to the presence of angiectasias (p