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PubMed2005

Breast duct micro-endoscopy: a study of technique and a morphological classification of endo-luminal lesions.

Endoscopic visualisation of the human mammary ductal system has been sporadically reported over the last decade. Recent rapid and groundbreaking developments in the field of optics have made the previously unseen labyrinth of mammary ducts more easily accessible to direct visualisation and examination. The emphasis so far has been on visualisation of ectatic ducts with pathological nipple discharge. The purpose of this study was to assess the feasibility of mammary duct epithelium in patients with a range of other pathologies. Based on our findings we have developed a morphological classification of endo-luminal lesions seen on endoscopy. We successfully conducted ex vivo mammary duct micro-endoscopy on 115 ducts in 35 mastectomy specimens. Visualisation of mammary duct epithelium was achieved using a solid rod depth of field imaging micro-minimally invasive (DOFI MMI, Acueity Inc., USA) and more recently the LaDuScope (PolyDiagnost GmbH, Germany) system. Both these systems consist of 0.9 mm maximum outer diameter micro-endoscope, with working channels 0.35 and 0.45 mm, respectively. Saline or air insufflation was used to keep the mammary ducts from collapsing. An average of 3.3 (median 3) mammary ducts could be identified and cannulated in all 35 mastectomy specimens (total of 115 ducts). Visualisation beyond 2 cm of the ductal system was possible in 23/35 (66%) of specimens. Abnormalities were visualised in 40% of the ducts. The maximum depth we could negotiate to was 8.9 cm and in doing so manoeuvred past eight duct divisions. In 34% of ducts cannulated, we were able to navigate the scope beyond at least one bifurcation of the principal duct and in 16% of cases extensive intra-ductal navigation was possible. Peripheral ducts were visualised in 16% of cases. False passages were created in 16% of cases. Previous history of smoking, parity, breastfeeding and radiotherapy offered neither significant advantages nor disadvantages for the technique nor did they increase or decrease the number of normal ducts visualised per specimen. This study showed that mammary duct micro-endoscopy is a practical and technically feasible procedure even in the absence of nipple discharge, in normal non-ectatic milk ducts. A simple morphological classification of endoscopically visualised intra-ductal abnormalities is suggested.

Adult↗
PubMed2004

The role of upper endoscopy in identifying oesophageal involvement in patients with oral pemphigus vulgaris.

BACKGROUND AND AIMS: The involvement of oesophagus in pemphigus vulgaris is still debated. The aims of this study were to evaluate the prevalence of oesophageal involvement and the gastro-duodenal mucosa appearance before and after high-dose corticosteroid therapy in a group of patients with oral pemphigus vulgaris. METHODS: We prospectively studied 28 consecutive patients with oral pemphigus by oesophageal symptom standardised questionnaire, upper gastro-intestinal endoscopy, exfoliative cytology and histological biopsy. After clinical remission, all patients underwent new endoscopy. RESULTS: The prevalence of oesophageal symptoms was 57.1%. Endoscopic examination revealed oesophageal involvement with different degrees of severity in 67.8% of patients. After corticosteroid therapy, endoscopy showed normal oesophageal-gastro-duodenal mucosa. No examination-related exacerbations of the oesophageal lesions were seen. CONCLUSIONS: The upper gastro-intestinal endoscopic examination, in oral pemphigus vulgaris patients with oesophageal symptoms, is safe in skilled hands technique and a useful diagnostic tool prior to starting therapy.

Drug Therapy, Combination↗
PubMed2006

Videocapsule endoscopy is useful for the diagnosis of intestinal lymphangiectasia.

We study two authentic cases of protein-losing enteropathy, the diagnosis of which was facilitated using Given M2A videocapsule endoscopy. The first case corresponded to a primary intestinal lymphangiectasia confirmed by jejunum biopsies and the second one to a protein-losing enteropathy with lymphatic abnormalities secondary to a chronic constrictive pericarditis. In the first case, the mucosa of jejunum presented with a diffuse oedematous aspect, whitish villi, white curved lines probably related to submucosal dilated lymphatics and lacteal juice. In the second case, capsule endoscopy showed oedematous aspect of jejunum mucosa associated with white curved lines similar to those observed in the first case. Videocapsule endoscopy is useful in cases of protein-losing enteropathy to identify presence of intestinal lymphangiectasia and to specify their localisation after ruling out other disorders liable to induce protein-losing gastrointestinal syndrome.

Adult↗
PubMed2004

Effect of suprarenal stent struts on the renal artery with ostial calcification observed on CT virtual intravascular endoscopy.

OBJECTIVES: The behaviour of stent struts crossing the renal ostia and their effect on renal ostia configuration is not well understood. The study aims to investigate whether suprarenal stent struts affect the morphological change of the renal artery with ostial calcification observed on CT virtual intravascular endoscopy. METHODS: Nine patients with abdominal aortic aneurysms undergoing suprarenal fixation of stent grafts were included in the study. All patients received a Zenith endovascular graft with uncovered suprarenal components placed above the renal arteries. Renal ostial calcification and configuration of stent wires crossing the renal ostium were characterized in each patient and maximal transverse and longitudinal diameters of the renal ostia were measured on virtual endoscopy pre- and post-stent grafting. RESULTS: There were altogether 17 renal ostia assessed with one patient having atrophic left kidney and no renal ostium being observed. Ostial calcification was found in five of the left renal ostia and five of the right renal ostia with one patient having bilateral ostial calcification. There was no significant difference between the renal ostial diameters measured pre- and post-stent grafting (p>0.05). Suprarenal stent struts were found to cross the renal ostia in various configurations observed on virtual endoscopy. All of the renal arteries were patent on follow-up CT scans after suprarenal fixation without stenosis or occlusion being observed. One patient with atrophic left renal artery developed renal failure following suprarenal stent grafting and received renal dialysis, while in the remaining cases median serum creatinine level did not change significantly. CONCLUSIONS: Suprarenal stent struts did not significantly affect the renal ostia with ostial calcification in terms of the diameter measurements and renal function. Further studies deserve to investigate the long-term effect of stent struts on the renal artery in terms of cross-sectional area reduction caused by stent wires and ostial calcification.

Aged↗
PubMed2004

Patient-controlled analgesia and sedation in gastrointestinal endoscopy.

Variations in pain threshold, drug tolerance, and visceral sensitivity among patients make it difficult to anticipate the appropriate dose of sedation for gastrointestinal endoscopy. Propofol was recently introduced for sedation in endoscopy and has a rapid onset and offset of action, making it an ideal substance for patient-controlled administration. Several controlled trials have demonstrated that during colonoscopy, patient-controlled application of propofol alone or in combination with various opioids is effective,safe, and yields high patient satisfaction. Target-controlled infusion of propofol has shown encouraging results for prolonged upper endoscopy procedures like endoscopic retrograde cholangio pancreatography.

Analgesia, Patient-Controlled↗
PubMed2004

Enhanced magnification endoscopy in the upper gastrointestinal tract.

In diseases such as Barrett's esophagus and celiac disease, the mucosal abnormality is patchy or irregular, highlighting the need for targeted biopsies. Enhanced magnification endoscopy is an effective, readily available method that can be used to assist in target biopsies and endoscopic diagnosis leading to an endoscopic classification system. The technique is not difficult and adds only an additional 5 to 10 minutes to a standard endoscopic procedure;however, most endoscopists never receive instruction in magnification endoscopy during their training. The value of this technique is still being explored, but the improvement in diagnostic accuracy will have an impact on decreasing morbidity and mortality without a large increase in cost. Increased use of this technique will aid in the diagnosis of celiac disease and simplify the classification system for Barrett's esophagus. Using enhanced magnification endoscopy at multiple centers in studies will help to determine the intra- and inter-observer variability, define the endoscopic criteria for dysplasia and early neoplastic changes, and standardize the visualized mucosal patterns more clearly.

Acetic Acid↗
PubMed2005

Investigation of the small bowel in gastrointestinal bleeding--enteroscopy and capsule endoscopy.

The last frontier in luminal endoscopy has been conquered. Bleeding lesions in the small intestine can present a frustrating clinical problem, but recent advances have made investigating the small bowel easier and less invasive. Capsule endoscopy and double balloon enteroscopy are two new technologies that promise to lower the barrier to evaluation of the entire small intestine. Recent studies show that capsule endoscopy improves outcomes in patients who have OGIB. Although outcome studies regarding double balloon enteroscopy have not been performed, the opportunity to treat lesions throughout the small bowel without resorting to surgery is a tremendous advance. These improvements suggest that the corner may have been turned in the diagnosis and management of small bowel bleeding. Perhaps to the next generation of gastroenterologists, small bowel bleeding will not be obscure.

Capsules↗
PubMed2006

Selective upper endoscopy for foreign body ingestion in children: an evaluation of management protocol after 282 cases.

PURPOSE: Foreign body ingestion is a common problem in both children and adults. This study aims to evaluate a management protocol where endoscopic examination was only selectively used after routine direct laryngoscopy to minimize patient discomfort and the need for general anesthesia in children. METHOD: A management protocol for foreign body ingestion based on symptoms was introduced in 1998 and records of children admitted to a university-affiliated hospital between January 1999 and October 2005 with suspected foreign body ingestion were evaluated. Symptoms, radiologic and endoscopic findings, and outcome were reviewed. RESULTS: A total of 282 patients were admitted. The mean age of patients was 5.75 years (range, 9 months to 17 years). There were 167 boys and 115 girls. Based on our protocol, 84 (29.8%) patients required an upper endoscopy. Fish bones were most commonly involved (68.8%). Foreign bodies, which were either removed or dislodged, were found during upper endoscopy in only 25 (8.8%) patients overall. All patients had an uneventful outcome. No complications or mortalities were encountered. There were no readmissions for those who did not undergo endoscopic examination. CONCLUSION: It is safe to selectively perform upper endoscopy depending on symptoms when managing children with foreign body ingestion.

Adolescent↗
PubMed2003

Unsedated transnasal endoscopy (the Shaker technique): an alternative for assessment of supraesophageal complications of gastroesophageal reflux.

This article reviews problems associated with sedated endoscopy, and describes the rationale for unsedated endoscopy as an alternative. Costs, tolerability, potential for complications, and general patient and physician acceptance for unsedated endoscopy are reviewed. A new technique, the transnasal esophagogastroduodenoscopy (the Shaker technique), is described.

Procedural Sedation↗
PubMed1999

Is upper gastrointestinal endoscopy indicated in asymptomatic patients with a positive fecal occult blood test and negative colonoscopy?

PURPOSE: There are no recommendations as to whether endoscopic evaluation of the upper gastrointestinal tract is indicated in asymptomatic patients who have a positive fecal occult blood test and a negative colonoscopy. SUBJECTS AND METHODS: All asymptomatic patients with a positive fecal occult blood test who were referred for diagnostic endoscopy were identified. Patient charts, endoscopy records, and pathology reports were reviewed. RESULTS: During the 5-year study period, 498 asymptomatic patients with a positive fecal occult blood test and negative colonoscopy were evaluated. An upper gastrointestinal source of occult bleeding was detected in 67 patients (13%), with peptic ulcer disease being the most common lesion identified (8%). Four patients were diagnosed with gastric cancer and 1 had esophageal carcinoma. In addition, 74 patients (15%) had lesions that were not considered a source of occult bleeding; these findings prompted a change in management in 56 patients (11%). Anemia was the only variable significantly associated with having a clinically important lesion identified (multivariate odds ratio = 5.0; 95% confidence interval 2.9 to 8.5; P <0.001). CONCLUSIONS: Upper gastrointestinal endoscopy yields important findings in asymptomatic patients with a positive fecal occult blood test and negative colonoscopy. Our data suggest that endoscopic evaluation of the upper gastrointestinal tract should be considered, especially in patients with anemia.

Aged↗
PubMed1991

Barium meal or endoscopy? A prospective randomized study of patient preference and physician decision making.

This study examines the preference of 64 out-patients for either a barium meal or an upper gastrointestinal endoscopy. The sequence of the examinations was randomized to avoid order bias. An initial preference for a barium meal of almost two-to-one, with 53% having no preference, was changed after the investigations to a preference for endoscopy of two-to-one with 5% having no preference. The use of mild sedation and the skill of the endoscopist had a major impact on the patients' opinion of the endoscopic procedure, and on their choice of examination for any repeat study. There was little agreement between clinical diagnosis and the result of investigation, but clinicians tended to accept the reported result of the investigation, especially if the result was abnormal. Despite a change in diagnosis in 34 of 49 patients there was little change in management as a result of the investigations, supporting the view that young patients with dyspepsia may be managed with symptomatic treatment initially, and without investigation. This study lends further support to the view that endoscopy should be the investigation of choice in patients with persistent dyspepsia, especially those whose age or infirmity may make barium examination suboptimal.

Barium Sulfate↗
PubMed1983

The double-contrast barium meal: a correlation with endoscopy.

The radiological and endoscopic findings are described in 214 patients with 252 lesions in whom endoscopy had been requested by a radiologist either to confirm or clarify a radiological opinion. There was radiological and endoscopic agreement about the presence or absence of oesophagitis in 73% of patients, but there was agreement about the presence or absence of duodenitis in only 48%. There were only two cases of early gastric cancer, and no early gastric cancers were found in a group of 43 patients on whom endoscopy had been specifically requested because of an abnormal gastric mucosal pattern. Endoscopy failed to detect 13% of gastric ulcers at the initial endoscopic examination.

Barium Sulfate↗
PubMed1975

Correlation between hysterosalpingography and pelvic endoscopy for the evaluation of tubal factor.

In this study of 132 infertile couples, findings with hysterosalpingography (HSG) were compared with those observed at subsequent culdoscopy or laparoscopy. Both procedures correctly revealed normal tubes in 29% of the subjects and identical abnormalities in 24%. A complete agreement between the two procedures was thus observed in 53% of women. Hysterosalpingography showed 5% false positive and 14% false negative findings. In the remaining cases the type of anomaly revealed by HSG was different from that found at laparoscopy. Peritubal adhesion was the pathologic process most commonly missed by HSG and diagnosed subsequently by endoscopy. Pelvic endoscopy also revealed endometriosis and other pelvic disease in a high proportion of women, whereas HSG exclusively detected all intrauterine lesions. Similar pregnancy rates resulted when HSG and endoscopy revealed normal organs. The significance of these findings is discussed.

Adult↗
PubMed2001

The comparison of midazolam and topical lidocaine spray versus the combination of midazolam, meperidine, and topical lidocaine spray to sedate patients for upper endoscopy.

BACKGROUND: Whether an opiate-benzodiazepine combination is superior to benzodiazepine alone for sedation in upper endoscopy is controversial. The purpose of this study was to compare the effectiveness of intravenous midazolam alone versus the combination of intravenous midazolam and intravenous meperidine for the sedation of patients undergoing upper endoscopy. METHODS: One hundred seven patients scheduled for outpatient diagnostic esophagogastroduodenoscopy were randomly assigned to receive 50 mg intravenous meperidine (53 of 107) or placebo (54 of 107). All patients received topical lidocaine spray and as much midazolam as the endoscopist thought the patient needed. Patients and endoscopists were blinded as to assignment. Data collected included intubation time (seconds), procedure time (minutes), pulse, blood pressure, complications, and the need for reversal agents. The endoscopist evaluated the quality of sedation immediately after the procedure (1 = excellent, 2 = good, 3 = fair, and 4 = poor). The patient evaluated the procedure the next day by phone (1 = no discomfort or did not remember, 2 = slightly uncomfortable, 3 = extremely uncomfortable, and 4 = unacceptable). Patients were also asked whether they would agree to another esophagogastroduodenoscopy if their doctor thought it was medically necessary. RESULTS: The intubation time, procedure time and blood pressure were not significantly different between the 2 groups. In comparing the meperidine group versus placebo group, the highest pulse (82.3 vs. 93.7, p = 0.0010), lowest pulse (67.2 vs. 72.3, p = 0.0194) and amount of midazolam used (4.0 vs. 4.8 mg, p = 0.0185 or 0.53 vs. 0.67 mg/kg, p = 0.0083) were significantly different by using a t test analysis. Patient evaluations comparing meperidine versus placebo showed responses of 1 (52 vs. 49), 2 (1 vs. 3), 3 (0 vs. 2) and 4 (0 vs. 0), which were not significantly different. The endoscopists'evaluation comparing meperidine versus placebo gave responses of excellent (44 vs. 27), good (6 vs. 22), fair (3 vs. 5) and poor (0 vs. 0), which were highly significantly different (p < 0.001) by using chi-square statistical techniques. CONCLUSION: The addition of meperidine to midazolam in sedating patients undergoing upper endoscopy adds no benefit from the patient viewpoint, whereas endoscopists favored the use of both medications.

Administration, Topical↗
PubMed2003

The role of endoscopy in the evaluation and treatment of patients with pancreaticobiliary malignancy.

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.

Adenocarcinoma↗
PubMed2003

Transluminal endosurgery: single lumen access anastomotic device for flexible endoscopy.

BACKGROUND: Forming anastomoses between two hollow organs at flexible endoscopy might reduce the need for surgery for obstructing malignancy. Current methods require access to both lumens. The aim of this work was to develop methods of forming an anastomosis at flexible endoscopy, such as a gastrojejunostomy or cholecystoduodenostomy, when access to only one lumen is feasible. METHODS: A modified needle was passed through a large-channel echoendoscope from the accessible lumen into the target hollow organ. An anastomotic device was formed by using two 7F catheter segments, which were pushed over a guidewire into the target, the less accessible lumen. When released, by withdrawing the guidewire, the catheters formed a cross shape and created an anastomosis when compressed against a plate from the accessible side. OBSERVATIONS: These devices were tested in live animal experiments. With an echoendoscope in the stomach, it was repeatedly possible to place needles, threaded tags, and guidewires into the small intestine and gallbladder. In 4 to 7 days, anastomoses were formed in 16 pigs between the small intestine and the stomach, and between the gallbladder and the stomach. The initial diameter of the anastomoses ranged from 3 to 9 mm. No complication occurred. CONCLUSIONS: It is feasible to form anastomoses at flexible endoscopy when access is limited to a single side.

Anastomosis, Surgical↗
PubMed2004

Safety and effectiveness of ketamine as a sedative agent for pediatric GI endoscopy.

BACKGROUND: The ideal sedation for children undergoing GI endoscopy remains elusive. After ketamine was introduced as a sedative agent in our GI procedure suite, improved sedation and reduced complications were observed. The aim of this study was to assess the safety and effectiveness of ketamine as a sedative agent for GI endoscopy in pediatric patients. METHODS: A retrospective cohort study of 402 procedures (EGD, colonoscopy) was performed. Sedation-related complications were defined as hypoxia (oxygen saturation <95% by pulse oximetry), agitation, emergence reactions, stridor, laryngospasm, nausea, vomiting, aspiration, and muscle twitching, or any combination thereof. Sedation groups were defined as the following: Group I, midazolam and meperidine (n=192); Group II, midazolam, meperidine, and ketamine (n=82); and Group III, midazolam and ketamine (n=128). RESULTS: Group 1 (midazolam and meperidine) had the highest frequency of complications, most commonly hypoxia. Group 3 (midazolam and ketamine) had the lowest rate of complications (p=0.001) and the highest rate of adequate sedation, although the difference was not significant (p=0.07). CONCLUSIONS: The combination of midazolam and ketamine appears to provide safe and effective sedation for pediatric patients undergoing endoscopy.

Child↗
PubMed2004

Assessing clinical generalizability in sedation studies of upper GI endoscopy.

BACKGROUND: Prior endoscopic studies evaluating conscious sedation have recruited only a small proportion of the patients actually approached. The generalizability of such results to an unselected adult ambulatory care population is thus questionable. The objectives of this study were to determine the characteristics of patients who refused inclusion in a randomized controlled trial of sedation and to compare these characteristics to those of patients who agreed to participate. METHODS: Patients who refused participation in a randomized controlled trial of sedation completed standardized questionnaires addressing demographic data and possible confounding variables, and they also completed a validated anxiety questionnaire. Characteristics associated with refusal to participate in the randomized controlled trial were assessed by using uni- and multivariate analysis. Exploratory comparisons of outcomes between both groups included self-reported satisfaction with level of comfort and technical adequacy. RESULTS: Of 302 patients screened, 203 refused to participate in the randomized controlled trial. The most common reason for refusal was the request for no sedation (135/203). A total of 163 were enrolled in this synchronous study. Patients who refused to participate exhibited 3 distinguishing characteristics: prior treatment for an anxiety disorder (risk difference 9.4%: 95% CI[3%, 17%]), use of analgesic medication (risk difference 10.4%: 95% CI[2%, 19%]), and prior experience with EGD (risk difference 17.9: 95% CI[5%, 30%]). Only upper endoscopy experience was predictive of refusal to participate in the randomized controlled trial. No differences in outcomes existed between patients randomized to sedation and those refusing the randomized controlled trial who chose to receive sedative medication. Patients who refused participation in the randomized controlled trial and who underwent upper endoscopy without sedation were more satisfied than patients randomized to placebo (1.33 vs. 2.58; risk difference -1.25: 95% CI[-0.38, -2.1]). Moreover, the procedure in these patients was more adequate technically (4.86 vs. 4.18; risk difference 0.68: 95% CI[0.21, 1.13]). CONCLUSIONS: Characteristics of patients accepting and refusing randomization were highly similar, differing only with regard to upper endoscopy experience. An exploratory analysis of outcomes suggests that randomized controlled trial results may be biased in a direction that may underestimate the benefits of not administering sedative medication in a real-life setting.

Adolescent↗