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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.

Video Video 1 Remote training in flexible GI endoscopy.

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.

Many different techniques for colon cancer screening are available. The fecal immunochemical test is best for fecal-based screening, although the DNA investigation may be more specific when further developed. Computed tomographic colonography is as good as colonoscopy for detecting colon cancer and is almost as good as colonoscopy for detecting advanced adenomas, but has limitations. The flexible sigmoidoscopic examination markedly decreases the incidence of cancer in the visualized segments, but colonoscopy is currently the best procedure for evaluating the large bowel. Techniques for retroflexion or backward view of the colon have been investigated, with all showing increased polyp detection.

The high-resolution microendoscope (HRME) is a novel imaging modality that may be useful in the surveillance of Barrett's esophagus in low-resource or community-based settings. In order to assess accuracy and interrater reliability of microendoscopists in identifying Barrett's-associated neoplasia using HRME images, we recruited 20 gastroenterologists with no microendoscopic experience and three expert microendoscopists in a large academic hospital in New York City to interpret HRME images. They prospectively reviewed 40 HRME images from 28 consecutive patients undergoing surveillance for metaplasia and low-grade dysplasia and/or evaluation for high-grade dysplasia or cancer. Images were reviewed in a blinded fashion, after a 4-minute training with 11 representative images. All imaged sites were biopsied and interpreted by an expert pathologist. Sensitivity of all endoscopists for identification of high-grade dysplasia or cancer was 0.90 (95% confidence interval [CI]: 0.88-0.92) and specificity was 0.82 (95% CI: 0.79-0.85). Positive and negative predictive values were 0.72 (95% CI: 0.68-0.77) and 0.94 (95% CI: 0.92-0.96), respectively. No significant differences in accuracy were observed between experts and novices (0.90 vs. 0.84). The kappa statistic for all raters was 0.56 (95% CI: 0.54-0.58), and the difference between groups was not significant (0.64 vs. 0.55). These data suggest that gastroenterologists can diagnose Barrett's-related neoplasia on HRME images with high sensitivity and specificity, without the aid of prior microendoscopy experience.

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.

Chromoendoscopy-Targeted Biopsies Are Superior to Standard Colonoscopic Surveillance for Detecting Dysplasia in Inflammatory Bowel Disease Patients: A Prospective Endoscopic Trial

Resumen Introduccion El diverticulo colonico invertido (DCI) tiene una apariencia similar a las lesiones polipoideas elevadas. El objetivo del presente estudio es describir las caracteristicas endoscopicas del DCI a fin de evitar errores en el diagnostico y reportar la frecuencia de estas lesiones. Material y metodo Se realizo un analisis retrospectivo de todos los pacientes que se sometieron a una colonoscopia entre julio de 2001 y julio de 2004, usando una base de datos endoscopicos. Se incluyeron los pacientes con diagnostico de DCI y se analizaron sus caracteristicas. Con respecto al DCI, se registro la localizacion, las caracteristicas endoscopicas y la presencia de polipos colonicos sincronicos. Resultados Entre las 4.508 colonoscopias realizadas, 33 pacientes (0,7%) tuvieron el diagnostico de DCI. La edad promedio de los pacientes fue de 62,3 anos, y hubo un leve predominio del sexo femenino con una relacion 1:1,2. El 89 % de los DCI se localizo en un area de diverticulosis, y el 75% se localizo en el colon sigmoides. Un paciente presento una hemorragia digestiva activa con su origen en el diverticulo invertido y se trato con inyectoterapia. Se describieron las caracteristicas endoscopicas del DCI. No se reportaron complicaciones en esta serie. Conclusiones El DCI es un hallazgo endoscopico raro que puede complicarse por el sangrado local. El error diagnostico puede ser peligroso y su biopsia o reseccion conllevarian graves complicaciones. Los criterios diagnosticos descritos deberian considerarse para evitar la aparicion de complicaciones.

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.

The removal of colon polyps is the commonest therapeutic maneuver performed in the large bowel. The technique for polypectomy of small or large polyps is basically the same, with repetitive but similar actions required for larger lesions. Several steps are described that make polypectomy more efficient. These include straightening the colonoscope, placing the polyp in the correct position, keeping the snare flat on the wall during closure and aspiration of air. Bleeding can be controlled with injection of a vasoconstrictor or application of loops and clips. Not all polyps can be removed but if surgery is contemplated, injection of a surgical marker will be of assistance to the surgeon when seeking the area requiring resection.

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

The term submucosal injection polypectomy (SIP) more accurately describes the technique used for removal of flat colonic polyps and is preferred, in the colon, to endoscopic mucosal resection (a procedure that usually uses a special suction-activated device). Using SIP, most polyps can be removed safely from any part of the colon. The methodology is described in detail and is within the capability of most colonoscopists.

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 After patients have undergone colonoscopic polypectomy, it is uncertain whether colonoscopic examination or a barium enema is the better method of surveillance. Methods As part of the National Polyp Study, we offered colonoscopic examination and double-contrast barium enema for surveillance to patients with newly diagnosed adenomatous polyps. Although barium enema was performed first, the endoscopist did not know the results. Results A total of 973 patients underwent one or more colonoscopic examinations for surveillance. In the case of 580 of these patients, we performed 862 paired colonoscopic examinations and barium-enema examinations that met the requirements of the protocol. The findings on barium enema were positive in 222 (26 percent) of the paired examinations, including 94 of the 242 colonoscopic examinations in which one or more adenomas were detected (rate of detection of adenomas, 39 percent; 95 percent confidence interval, 33 to 45 percent). The proportion of examinations in which ...

The millennium provides an opportunity to contemplate and review the recent past and to plan for the future. The last half century, in particular, has been the golden age of gastroenterology, wherein rigorous, scientifically based medicine has revolutionized gastrointestinal diagnosis and therapy. The technologic fantasy and science fiction of 50 years ago has become the real and commonplace. The peptic ulcer that was treated by the Sippy meal, gastric freezing, or gastric radiation 50 years ago is now treated by scientifically based pharmacotherapy, including potent proton-pump inhibitors and antimicrobial therapy. The cecal adenoma that required inpatient laparotomy and colotomy for polypectomy 30 years ago is now simply removed by ambulatory colonoscopic polypectomy. The surgical gastrostomy for long-term enteral feeding of 20 years ago is replaced by percutaneous endoscopic gastrostomy. The awkward, painful, and sometimes dangerous semiflexible endoscope of 42 years ago has been replaced by the simple, convenient, and safe flexible endoscope. The word abdomen is derived from the Latin abdere , meaning hidden or concealed. 62 The flexible endoscope, the computed tomography (CT) scan, and the abdominal ultrasound study have opened this previously inaccessible organ to observation and inspection by the gastroenterologist, radiologist, and surgeon without surgery. The surgeon's knife has become the endoscopist's papillotome, and the laparotomy has become a laparoscopy. The diagnostic laparotomy has become nearly obsolete. The excitement at novel discoveries yields to complacency with time as the inconceivable becomes ubiquitous. Yet what human endeavor has contributed more to the betterment of humanity than medicine? For example, one simple gastroenterologic therapy—oral rehydration with glucose and electrolyte solution—has saved millions of lives per year worldwide from cholera. This revolution was accomplished not by the sword but by the pencil, not by rhetoric but by statistics, and not by climbing the ramparts but by toiling in the laboratory and clinic. This revolution is largely undocumented, unrecognized, and unpraised. The furious pace of magnificent discovery and invention and the preoccupation of the discoverers and inventors with discovery and invention have left little time for writing a history. A gastroenterologic history provides manifold salutary effects. First, individuals who toiled, created, and invented receive overdue and well-deserved recognition. Second, a history provides role models to the initiate or student in gastroenterology. Third, a historical perspective provides the discipline an identity, purpose, and mission. Fourth, a history collates, categorizes, and clarifies the important issues in gastroenterology. An historical perspective helps outline important ongoing areas of controversy and research interest and suggests strategies, approaches, and techniques for further research. Fifth, a history that celebrates great past gastroenterologic achievements may cause legislators to reconsider draconian cutbacks in funding future worthy projects. A contemporaneous history is most meaningful because a contemporary can evaluate the impact of changes, with knowledge of past and present. Immediacy provides impact. This article is included in this issue of the Gastroenterology Clinics in honor of the millennium. To provide a proper perspective, Cappell asked several senior luminaries to vote as a committee on the 50 great landmarks during the past 50 years. The vote revealed surprising concordance, with the largest discrepancy being a difference in six of the selected landmarks. The importance and history of each landmark discovery is discussed to provide an appropriate vehicle for a brief modern history of gastroenterology. The first part of this historical essay, which discussed endoscopic, radiologic, and surgical techniques and upper gastrointestinal disorders, was presented in the March 2000 issue of the Gastroenterology Clinics . This second part completes the historical essay.

During the last half century, many outstanding discoverers have revolutionized the clinical practice and science of gastroenterology. Whereas the scientific results are widely disseminated, the discoverers have received inadequate recognition, and the history of their discoveries is poorly known. At the millennium, a committee selected the 50 landmark discoveries in gastroenterology during the past 50 years. A brief history of each landmark discovery is presented. Part I presents the landmark discoveries in gastrointestinal (GI) procedures and in upper GI disorders. Part II of this presentation, which covers landmark discoveries in other areas of gastroenterology, will publish in Part II of the volume on High Risk Gastrointestinal Bleeding.

Background & Aims: Adenomatous polyps are by definition dysplastic and pathologically indistinguishable from the dysplasia-associated lesion or mass (DALM) described in 1981. Yet, adenomatous polyps in noncolitic colons are usually removed definitively endoscopically, whereas DALMs are regarded as harbingers of colon cancer, mandating colectomy. Methods: Since 1988, all of our patients with chronic ulcerative or Crohn's colitis and dysplastic polyps and no coexistent dysplasia in flat mucosa underwent colonoscopic polypectomy. Biopsy specimens were obtained also adjacent to polypectomy sites, from strictures, and throughout the colon at 10-cm intervals. Follow-up colonoscopies and biopsies were performed within 6 months after polypectomy and yearly thereafter. Results: Colonoscopy in 48 patients with chronic colitis (mean duration, 25.4 years) resected 70 polyps (60 in colitic and 10 in noncolitic mucosa). Polyps were detected on screening colonoscopies (29%) and on surveillance (71%). Pathology was tubular adenoma in all polyps from noncolitic mucosa and low-grade dysplasia (57), high-grade dysplasia (2), or carcinoma (1) in polyps from colitic mucosa. Subsequent colonoscopies (mean follow-up, 4.1 years) revealed additional polyps in 48% but no carcinomas. Surgical resection (6 patients) for recurrent polyps confirmed colonoscopic findings. No dysplasia or cancers in flat mucosa were found at surgery or on follow-up colonoscopies. Conclusions: In patients with chronic colitis who have no dysplasia in flat mucosa, colonoscopic resection of dysplastic polyps can be performed effectively, just as in noncolitic colons. GASTROENTEROLOGY 1999;117:1295-1300

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.)

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.