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Periodontal regeneration is an old idea that is evolving because to the adoption of more modern and altered barrier membranes to get better clinical results. The placental amnion and chorion membranes are examples of these membranes. Its biocompatibility and capacity to speed up wound healing led to its initial use.As part of guided tissue regeneration and guided bone regeneration, the membrane has been utilised in periodontology to reduce probing pocket depth, raise clinical attachment levels, and encourage bone formation. Since these membranes are biologic, they can be broken down by the body and work with tissue.It has also been utilised to treat intrabony abnormalities, guided bone regeneration, and root covering therapies. The special characteristics of this membrane that make it ideal for periodontal surgery, together with the clinical repercussions and literature evaluation.

The CUSA is a device of modern periodontal treatment that claims to be a breakthrough in minimal invasion surgical technique. While repairing a ship's propeller in 1916, scientist Lord Rayleigh discovered the effect of cavitation. This device, like others, uses low frequency ultrasonic radiation to dissect or split tissues with low fibre content. Ultrasonic pulses in the 23 kHz range are used to create cavitations in tissue a hollow 3 mm tip vibrating at 23,000 times per second delivers this mechanical energy. CUSA is a surgical device that was developed for ophthalmology but has since gained widespread acceptance in a number of medical disciplines, including neurosurgery, general surgery, gynaecology, urology, and neurotology. This equipment cause, Biofilm disruption and cell stimulation for non-surgical treatment of infrabony defects, as well as ultrasonic debridement and flapless therapy, are said to be effective. Using this aspirator increases safety and quality while decreasing operational time. There are no known contraindications, but there are financial and personal constraints. As a result, this strategy appears to be a viable option for improving non-surgical minimally invasive therapeutic procedures

Iatrogenic portobiliary fistula is a rare complication following endoscopic biliary stent placement. Damage to the portal vein following endoscopic biliary stent placement has previously only been reported as single case reports. Management has ranged from conservative monitoring to surgery. Here we present four cases of inadvertent endoscopic placement of a biliary stent into the portal vein. Interventional radiology was called to assist in the management of each of these cases. The experience presented here in conjunction with review of previously reported cases helps shed light to potential management strategies if this complication is encountered in the future.

Impact of Endotracheal Intubation on Interventional Endoscopy Unit Efficiency Metrics at a Tertiary Academic Medical Center

Noninvasive imaging with CT and magnetic resonance enterography or direct visualization with wireless capsule endoscopy can provide valuable diagnostic information and direct therapy. Enteroscopy technology and techniques have evolved significantly and allow diagnosis and therapy deep within the small bowel, previously attainable only with intraoperative enteroscopy. Push enteroscopy, readily available in most endoscopy units, plays an important role in the evaluation and management of lesions located up to the proximal jejunum. Currently available device-assisted enteroscopy systems, DBE, SBE, and spiral enteroscopy each have their technical nuances, clinical advantages, and limitations. Newer, on-demand enteroscopy systems appear promising, but further studies are needed. Despite slight differences in parameters such as procedural times, depths of insertion, and rates of complete enteroscopy, the overall clinical outcomes with all overtube-assisted systems appear to be similar. Endoscopists should therefore master the enteroscopy technology based on institutional availability and their level of technical expertise.

Background and study aims: There is an increasing demand for interventional endoscopic services and the need to develop efficient endoscopic units. The aim of this study was to analyze performance data and define metrics to improve efficiency in a single academic interventional endoscopy center. ]Patients and methods: The prospective operations performance data (6-month period) of our interventional endoscopy unit (EU) was analyzed. First-case start time (FIRST) delay was defined as any time the first patient of the day entered the endoscopy room after the scheduled time. Non-endoscopy time (NET) and total time (TT) were defined as non-procedural and total time elapsed in the EU, respectively. Time-interval between successive patients (TISP) was defined as the time from one patient departure from the room until the time of arrival of the next patient in the room. Results: A total of 1421 patients underwent 1635 endoscopic procedures. FIRST was delayed (54.2 % cases) by 13.6 min (range 1 – 53), but started within 15 min of the scheduled time in 85 % of the cases. NET accounted for 9.1 hours (67.2 %) of 13.5 hours TT/day. TISP (37.1 min, range 5 – 125) comprised 54.2 % of the NET, and was delayed (> 30 min) in 49.8 % of cases. “Patient flow” processes (registration, admission, transportation, scheduling) accounted for 50.1 % of TISP delays. Conclusions: Delays in NET, specifically TISP, rather than FIRST, were identified as a cause for decreased efficiency. “Patient flow” processes were the main reasons for delays in TISP. This study identifies potential process measures that can be used as benchmarks to improve efficiency in the EU.

Background and study aims: Esophagrams are often obtained routinely after pneumatic balloon dilation for achalasia, even in asymptomatic patients, as there is a risk of postprocedure esophagogastric perforation, which is a potentially life-threatening complication. The aim of this study was to determine whether the combination of a clinical suspicion of perforation and endoscopic re-examination after pneumatic dilation for achalasia can detect esophagogastric perforation, and thereby preclude the need for routine esophagrams in all patients. Patients and methods: All patients who underwent pneumatic dilation between January 2002 and June 2012 at our single tertiary referral center were identified retrospectively. Procedures were categorized into two groups: Group 1 underwent routine esophagograms after pneumatic dilation, and Group 2 underwent esophagograms only if there was a clinical suspicion of perforation. The detection rate of esophageal perforation after pneumatic dilation was compared between the two groups. Results: A total of 119 achalasia dilation procedures were performed in 70 patients. Group 1 included 49/119 procedures (41.2 %), all of which were followed by routine esophagograms. Group 2 included 70/119 procedures (58.8 %), 12 of which were followed by esophagograms based on a clinical suspicion of perforation. No esophageal perforations were found in Group 1, whereas three were found in Group 2. No perforations occurred in the 58 procedures that were not followed by esophagograms. The overall rate of perforation was 3/119 (2.5 %). Conclusions: Esophagrams obtained routinely after pneumatic dilation for achalasia did not reveal unsuspected esophagogastric perforations. No esophageal perforations were missed after procedures that were not followed by esophagograms. Obtaining an esophagram only in cases of clinical suspicion of perforation and endoscopic evaluation may be an alternative to routine esophagograms in patients undergoing pneumatic dilation for achalasia.

Advances in echoendoscopes and their processors have significantly expanded the role of EUS and its clinical applications.The diagnostic and therapeutic capabilities of EUS continue to evolve and improve. EUS has made a large impact on patient care but comes with significant startup and maintenance costs. As improved technology continues to enhance image resolution while decreasing the size of EUS processors, use of endosonography will become more widespread. EUS will continue to be a vital part of patient care and complement currently available cross-sectional imaging.

ESD is an established effective treatment modality for premalignant and early-stage malignant lesions of the stomach, esophagus, and colorectum. Compared with EMR, ESD is generally associated with higher rates of en bloc, R0, and curative resections and a lower rate of local recurrence. Oncologic outcomes with ESD compare favorably with competing surgical interventions, and ESD also serves as an excellent T-staging tool to identify noncurative resections that will require further treatment. ESD is technically demanding and has a higher rate of adverse events than most endoscopic procedures including EMR. As such,sufficient training is critical to ensure safe conduct and high-quality resections. A standardized training model for Western endoscopists has not been clearly established,but will be self-directed and include courses, animal model training, and optimally an observership at an expert center.Numerous dedicated ESD devices are now available in the United States from different manufacturers. Although the use of ESD in the United States is increasing, issues related to technical difficulty, limited training opportunities and mentors, risk of adverse events, long procedure duration,and suboptimal reimbursement may limit ESD adoption in the United States to a modest number of academic referral centers for the foreseeable future.

Electronic chromoendoscopy technologies provide image enhancement and may improve the diagnosis of mucosal lesions. Although strides have been made in standardization of image characterization, especially with NBI, further image-to-pathology correlation and validation are required. There is promise for the development of a resect and discard policy for diminutive adenomas by using electronic chromoendoscopy; however, before this can be adopted, further community-based studies are needed. Further validated training tools for NBI, FICE, and i-SCAN will also be required for the use of these techniques to become widespread.

INTRODUCTION: Oral melanomas are uncommon and similar to their cutaneous counterparts, are neoplasm that developed from melanocytic cells lying in the basal layer of the mucosa, its incidence is about 1.2 cases per 10 million inhabitants per year with a variation between 0.2% to 8% of all the melanomas and 0.5% of all the malignant neoplasias of the oral cavity.1 Oral conditions with increased melanin pigmentation are common; however, melanocytic hyperplasias are rare. The relative incidence amongst mucosal neoplasms of the head and neck had been reviewed by Hormia and Vuori2, about 7253 cases of malignancies of upper respiratory and gastrointestinal tracts between 1953-1964, five cases of oral melanoma were found with an incidence of 0.07%. Although, the melanocytic density has regional variation, facial skin has the greatest number of melanocytes. In oral mucosa, melanocytes 1: 10 basal cells, is seen.3 Cutaneous melanomas are etiologically linked to sun exposure, however risk factors for mucosal melanomas are unknown. They have no apparent relationship to chemical, thermal, or physical events. Intraoral melanocytic proliferations (nevi) are considered to be the potential sources of some oral melanomas. Currently, most oral melanomas are thought to arise de novo. Pathophysiology is thought to be initiated by biochemical alteration in the precursor cells. This triggers accelerated growth and invasive potential, but not necessarily progression from horizontal to vertical growth phases. In cutaneous melanomas, well-known differences exist in the biologic behaviors of the radial growth phase–melanoma (flat or macular), vertical growth phase– melanoma (mass, nodule, elevation), and vertical growth phase–melanoma with metastasis. Oral melanoma occurs more commonly in the Japanese, a male predilection exists with ratio being 2:1, and is seen to be diagnosed a decade earlier in males. The age ranges from 40 to 70 years, the average being 55 years4 and rare before 20years of age.5,6 The most frequent site is the hard palate followed by the maxillary gingiva,7,8 with rare sites being mandibular gingiva, buccal mucosa and floor of the mouth.9 Intraoral malignant melanomas are diagnosed clinically as pigmented lesion having irregular shape and outline.8 They remain asymptomatic and detected only when there is ulceration of the overlying epithelium and/or hemorrhage. This delayed detection may be the reason for the poor prognosis with the 5-year survival rate being between 15% to 38%.6,10 Invasion of the bone may occur, increasing the likelihood of metastasis. In addition, the rich vascular supply present in the oral cavity may further contribute to the dissemination of the melanomas.11

Background The surgical management of esophageal perforation (EP) often results in mortality and significant morbidity. Recent less invasive approaches to EP management include endoscopic luminal stenting and minimally invasive surgical therapies. We wished to establish therapeutic efficacy of minimally invasive therapies in a consecutive series of patients. Study Design An IRB-approved retrospective review of all acute EPs between 2007 and 2013 at a single institution was performed. Patient demographic, clinical outcomes data, and hospital charges were collected. Results We reviewed 76 consecutive patients with acute EP presenting to our tertiary care center. Median age was 64 ± 16 years (range 25 to 87 years), with 50 men and 26 women. Ninety percent of EPs were in the distal esophagus, with 67% of iatrogenic perforations occurring within 4 cm of the gastroesophageal junction. All patients were treated within 24 hours of initial presentation with a removable covered esophageal stent. Leak occlusion was confirmed within 48 hours of esophageal stent placement in 68 patients. Median lengths of ICU and hospital stay were 3 and 10 days, respectively (range 1 to 86 days). One-third of the patients were noted to have prolonged intubation (>7 days) and pneumonia that required a tracheostomy. One in-hospital (1.3%) mortality occurred within 30 days. Median total hospital charges for EP were $85,945. Conclusions Endoscopically placed removable esophageal stents with minimally invasive repair of the perforation and feeding access is an effective treatment method for patients with EP. This multidisciplinary method enabled us to care for severely ill patients while minimizing morbidity and mortality and avoiding open esophageal surgery.

Multiple endoscopic methods are available to treat symptomatic internal hemorrhoids. Because of its low cost, ease of use, low rate of adverse events, and relative effectiveness, RBL is currently the most widely used technique.

Over the last decade, WCE has established itself as a valuable test for imaging the small intestine. It is a safe and relatively easy procedure to perform that can provide valuable information in the diagnosis of small-bowel conditions. Its applications still remain limited within the esophagus and colon. Future developments may include improving visualization within the esophagus and developing technologies that may allow manipulation of the capsule within the GI tract and biopsy capabilities.

Background The diagnostic accuracy of cholangioscopy-guided sampling has not been rigorously evaluated. Objective To prospectively evaluate the accuracy of cholangioscopy-guided mini-forceps sampling and compare it with standard cytology brushings and forceps biopsies for the tissue diagnosis of indeterminate biliary lesions. Design Prospective, long-term follow-up, paired design cohort study. Setting Tertiary center. Patients Patients undergoing cholangioscopy for the evaluation of indeterminate biliary lesions. Interventions Each patient underwent triple sampling with cholangioscopy-guided mini-forceps, cytology brushing, and standard forceps. Main Outcome Measurements Diagnostic accuracy of each sampling method compared with the patient final status (cancer vs no cancer). Results A total of 26 patients (17 cancer positive/9 cancer negative) were enrolled. The mean follow-up in the patients with no cancer was 21.78 (SD ±6.78) months. The procedure was technically successful in all cases (100%). Sample quality was adequate in 25 of 26 (96.2%) of the cytology brushings, in 26 of 26 (100%) of the standard forceps biopsies, and in 25 of 26 (96.2%) of the mini-forceps biopsies. The sensitivity, accuracy, and negative predictive values were 5.9%, 38.5%, and 36% for standard cytology brushings; 29.4%, 53.8%, and 42.8% for standard forceps biopsies; and 76.5%, 84.6%, and 69.2% for mini-forceps biopsies, respectively. When comparing the 3 methods of sampling, mini-forceps biopsy provided significantly better sensitivity and overall accuracy compared with standard cytology brushing ( P P = .0215). Limitations Potential for selection bias. Conclusions Cholangioscopy-guided biopsies of indeterminate biliary lesions have significantly higher accuracy compared with ERCP-guided cytology brushings and standard forceps biopsies, but negative findings on mini-forceps biopsy cannot rule out malignancy with a high degree of certainty. (Clinical trial registration number: NCT01227382.)

Background Older systems for cholangiopancreatoscopy have demonstrated improved diagnostic and therapeutic abilities over standard ERCP but have shown limited feasibility. The SpyGlass Direct Visualization System addresses many of the shortcomings of the older platforms, but its potential advantages have not been rigorously evaluated. Objective To prospectively evaluate the feasibility, clinical efficacy, and safety of the SpyGlass system. Design Prospective cohort study. Setting Tertiary care center. Patients All patients undergoing cholangiopancreatoscopy at our institution. Interventions Cholangiopancreatoscopy with the SpyGlass system. Main Outcome Measurements Procedure success, defined as complete stone clearance for stone cases. For nonstone-related lesions, success was defined when all 3 of the following were met: (1) advancement of the SpyScope to the desired target, (2) adequate visualization, and (3) successful applications of all necessary diagnostic and/or therapeutic maneuvers. Results Overall, SpyGlass was successful in 70 of 75 patients (93.3%). In patients with biliary stones, complete stone clearance was achieved in 24 of 26 patients (92.3%). Cholangioscopy for nonstone-related indications was successful in 43 of 44 patients (97.7%). Pancreatoscopy was attempted in 5 patients and was successful in 3 (60%). The mean total procedure time (standard ERCP plus SpyGlass) was 64.3 minutes, the total SpyGlass time was 27.5 minutes, the mean SpyGlass visualization time was 14.2 minutes, the mean SpyBite sampling time was 12.1 minutes, the mean Spy therapy time was 8.4 minutes, and the mean set-up time was 5 minutes. There were 4 adverse events (4.8%). Limitations Single-center experience, no comparison group, potential for selection bias. Conclusions ERCP-guided cholangiopancreatoscopy with the SpyGlass system is technically feasible and can be successfully and safely performed in the vast majority of patients. (Clinical trial registration number: NCT00861198.)

Background. The utility of repeat EUS in patients with suspicion for pancreatic cancer after non-diagnostic EUS-FNA study is not well established.Aim. Determine the accuracy of repeat EUS-FNA in patients with suspected pancreatic cancer and prior non-diagnostic EUS-FNA.Methods. Retrospective cohort study.Results. From 2002 to 2008 in our institution 28 patients underwent repeat EUS-FNA for suspected pancreatic cancer. Initial EUS showed a pancreatic mass in 24 (85.71%), no mass in 3 (10.71%) and possible mass in 1 (3.58%). FNA was performed and was negative for malignancy in all patients. Repeat EUS showed pancreatic mass in 27 patients (96.42%) and no mass in 1 (3.58%). FNA was performed in all patients and cytology was positive for malignancy in 6 (21.43%). Out of the 28 patients, 17 (60.71%) were eventually confirmed to have cancer. Overall repeat EUS-FNA correctly determined the true final status in 17 out of 28 patients providing sensitivity for the diagnosis of cancer of 35% (95% CI 14%–62%), specificity 100% (95% CI 72%–100%), and overall accuracy of 61%, (95% CI 28%–72%).Conclusion. Repeat EUS-FNA provides reasonable accuracy and may be worthwhile in patients with suspected pancreatic cancer who had had prior negative EUS-FNA.

EMR has become an established therapeutic option for premalignant and early-stage GI malignancies, particularly in the esophagus and colon. EMR can also aid in the diagnosis and therapy of subepithelial lesions localized to the muscularis mucosa or submucosa. Several dedicated EMR devices are available to facilitate these procedures. Adverse event rates, particularly bleeding and perforation, are higher after EMR relative to other basic endoscopic interventions but lower than adverse event rates for ESD. Endoscopists performing EMR should be knowledgeable and skilled in managing potential adverse events resulting from EMR.

Introduction: Cancer of the head of the pancreas most commonly presents with obstructive jaundice and weight loss. In most US hospitals, these patients undergo a staging CT scan. In patients with obvious metastatic or unresectable disease, placement of an endoscopic expandable metal stent provides the most durable palliation. Most patients who are potentially resectable, based on CT scan and/or endoscopic ultrasonography, also undergo preoperative placement of an endoscopic biliary stent (plastic) as a “bridge” to surgery. This longstanding practice of placing a preoperative plastic biliary stent in those patients who are scheduled for an attempt at surgical cure was originally proposed as a method to restore the nutritional deficiencies associated with prolonged cholestasis. The hope was that this restoration would lead to fewer perioperative and postoperative complications. Very few randomized trials have studied the effect of preoperative drainage on outcomes, and the results of these have been inconclusive. The practice of preoperative stent placement has nonetheless continued at many centers. The recent publication of a very large and well-designed randomized, controlled clinical trial provides important new insights into the management of these patients with potentially resectable cancer of the pancreatic head.

In vivo real-time assessment of the histology of diminutive (≤5 mm) colorectal polyps detected at colonoscopy can be achieved by means of an "optical biopsy" by using currently available endoscopic technologies. This systematic review and meta-analysis was performed by the American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee to specifically assess whether acceptable performance thresholds outlined by an ASGE Preservation and Incorporation of Valuable endoscopic Innovations (PIVI) document for clinical adoption of these technologies have been met. We conducted direct meta-analyses calculating the pooled negative predictive value (NPV) for narrow-band imaging (NBI), i-SCAN, and Fujinon Intelligent Color Enhancement (FICE)–assisted optical biopsy for predicting adenomatous polyp histology of small/diminutive colorectal polyps. We also calculated the pooled percentage agreement with histopathology when assigning postpolypectomy surveillance intervals based on combining real-time optical biopsy of colorectal polyps 5 mm or smaller with histopathologic assessment of polyps larger than 5 mm. Random-effects meta-analysis models were used. Statistical heterogeneity was evaluated by means of I 2 statistics. Our meta-analyses indicate that optical biopsy with NBI, exceeds the NPV threshold for adenomatous polyp histology, supporting a "diagnose-and-leave" strategy for diminutive predicted nonneoplastic polyps in the rectosigmoid colon. The pooled NPV of NBI for adenomatous polyp histology by using the random-effects model was 91% (95% confidence interval [CI], 88–94). This finding was associated with a high degree of heterogeneity (I 2 = 89%). Subgroup analysis indicated that the pooled NPV was greater than 90% for academic medical centers (91.8%; 95% CI, 89-94), for experts (93%; 95% CI, 91-96), and when the optical biopsy assessment was made with high confidence (93%; 95% CI, 90-96). Our meta-analyses also indicate that the agreement in assignment of postpolypectomy surveillance intervals based on optical biopsy with NBI of diminutive colorectal polyps is 90% or greater in academic settings (91%; 95% CI, 86-95), with experienced endoscopists (92%; 95% CI, 88-96) and when optical biopsy assessments are made with high confidence (91%; 95% CI, 88-95). Our systematic review and meta-analysis confirms that the thresholds established by the ASGE PIVI for real-time endoscopic assessment of the histology of diminutive polyps have been met, at least with NBI optical biopsy, with endoscopists who are expert in using this advanced imaging technology and when assessments are made with high confidence.

OBJECTIVE The aim of this study was to evaluate predictors of malignancy in pancreatic lesions with suspicious or indeterminate endoscopic ultrasound fine-needle aspiration (EUS-FNA) cytology. METHODS Suspicious/indeterminate EUS-FNA cytology was identified from our database. Stable imaging, benign pathology, or survival for 12 months after EUS-FNA was considered benign. Diagnosis of malignancy was based on positive pathology, local invasion/metastasis on imaging, or death within 12 months from cancer-associated causes. Univariate analysis was performed to compare variables between benign and malignant lesions. Multivariate analysis (covariates: age [

Current methods to predict the development of severe pancreatitis are complex, cumbersome, and inaccurate. Simpler scoring systems like the one studied in this issue of the Journal are an improvement in simplicity but not in accuracy. More sophisticated approaches are needed for more accurate prediction, which would allow improved triage and management of these patients.