UEGW 2011 Report: Putting endoscopy into perspective

• Introduction
• Endoscopic resection and other endotherapy techniques
• New sophisticated imaging methods
• Narrow band imaging
• Fujinon intelligent chromoendoscopy
• High resolution/high definition magnifying endoscopy
• Endocytoscopy and confocal laser microscopy
• Autofluorescence imaging
• Barrett’s esophagus
• Gastrointestinal bleeding
• Enteroscopy topics
• Colonoscopy topics
• Endoscopic retrograde cholangiopancreatography and pancreatobiliary topics
• Endoscopic ultrasonography
• Natural orifice transluminal endoscopic surgery
• Percutaneous endoscopic gastrostomy
• References

Introduction

The 19th United European Gastroenterology Week (UEGW; 22 – 26 October 2011; Stockholm, Sweden) presented a unique opportunity for delegates interested in gastrointestinal endoscopy to update their knowledge as colleagues from around the world shared their experiences. Several interesting abstracts on endoscopic topics were presented, allowing participants to become acquainted with the latest advancements and current research in the field of gastrointestinal endoscopy. This report focuses on oral presentations and selected poster presentations and aims to review them in the light of recent literature.

Endoscopic resection and other endotherapy techniques

Endoscopic resection of early lesions (including pre-malignant pathologies and early gastrointestinal cancers) has been the focus of impressing advances during recent years [1]. Initially in the form of traditional endoscopic mucosal resection (EMR), the procedure has advanced more recently to tissue resection by endoscopic submucosal dissection (ESD). ESD has received most of the attention lately due to its ability to achieve en bloc resections of lesions larger than those resected by EMR, usually within the gastrointestinal tract [2] [3] [4] but occasionally even outside the “strict” anatomical limits of this structure [5]. Traditionally, expertise in ESD has been restricted to centers located in Asia [2] [3] [4] [5], where technique developments [6], advances in devices and instruments [7] [8] [9] [10], as well as new indications [11] [12] are usually presented firsts. Despite Asian dominance in ESD, experience has expanded recently to the West, including Europe [13] [14] [15] [16]. This growing experience was reflected by the presentation of European abstracts at UEGW 2010 [17] and an even larger variety of European studies on ESD at this year’s congress.

Naturally, EMR remains an attractive alternative for smaller lesions ( < 20 mm) or may be applied for piecemeal resection of larger ones [18] [19]. ESD, however, appears to produce better outcomes, as was shown in abstracts from Eastern as well as Western centers presented at UEWG 2011. An interesting multicenter study from Japan (from 18 centers) compared 805 ESDs with 1008 conventional endoscopic resections of 541 protruded, 1224 flat, and 48 depressed early colorectal neoplasias, and showed that the en bloc resection rate of ESD was significantly higher than that of conventional resections (95 % vs. 56 %). Furthermore, the complication rates were not significantly different (perforation and delayed bleeding rates were 1.9 % vs. 1.9 % and 0.8 % vs. 1.4 %, respectively), but at a cost of a longer procedure time (96 ± 69 vs. 18 ± 22 minutes) [20].

Growing expertise in ESD in the West was reflected in some interesting abstracts, including a report from a European center on their experience from 45 “challenging” polyps (due to size, difficult access or recurrence on previous EMR scars) in the rectosigmoid colon. These polyps were resected by ESD and compared with 100 lesions resected by EMR over a 5-year period [21]. Results showed that both techniques can achieve clearance of large (median size in both groups was 40 mm) and difficult left colonic polyps (ESD 91 % plus a further 7 % that were cleared in a subsequent procedure; EMR 90 %). However, complications with ESD were higher than with EMR (18 % vs. 8 %).

Some interesting European data from upper gastrointestinal tract ESDs were also reported [22]. ESD results were compared with historical results from piecemeal EMR for the treatment of superficial squamous cell esophageal carcinomas (27 by EMR since 1999 and 27 by ESD since 2007). En bloc resection was significantly higher in the ESD group (100 % vs. 26.7 %; P < 0.05) at a cost of longer excision time (102 vs. 51 minutes; P < 0.05). R0 resections were higher for ESD (76.7 % vs. 50.0 %; P < 0.05) but there was no difference in vascular invasion (16.7 % vs. 6.7 %). Eight and seven patients respectively received adjuvant therapy, and recurrence after a median follow-up period of 11.5 months was significantly lower with ESD (1 vs. 8 cases; P < 0.05), whereas the complication rate was similar (no perforations or bleeding but 17 % and 20 % strictures). A Japanese group presented two experimental studies that attempted to tackle the issue of stricture formation, which is a constant cause for concern in endoscopic resection, especially esophageal resections. In the first study, individual oral mucosal cell sheets were transplanted to the ulceration site in nine patients immediately after esophageal ESD. Patients experienced no dysphagia (apart from one case) and no stricture was observed endoscopically. Median time until complete healing was about 3 weeks [23]. Using a pig model, the same team confirmed the feasibility of transplantation of autologous skin epidermal cell sheets in an attempt to use a cell source other than oral mucosa, as skin can be harvested more easily [24].

It seems that the use of ESD will expand further in the future, as indications continue to become established for more complex diseases. Once again, centers from Asia are playing an important role in this area of innovation. For example, according to a Japanese study in which 83 lesions of clinically diagnosed cancer with submucosal invasion and 1295 lesions of intramucosal cancer were included, diagnostic ESD for the former group could be performed as safely as in the latter group. Resection by ESD of about 30 % of lesions invading the submucosa (especially those < 3 cm) was curative and gastrectomy was avoided [25]. Another study from Japan involved the removal of lesions associated with an ulcer scar in gastric ESD, a difficult task, as it is hard to identify an optimal dissection plane within the fibrotic submucosa [26]. This was achieved in 4 /5 attempts performed in two pigs using a newly designed balloon catheter, which created a submucosal tunnel underneath post-EMR scars. Finally, a large multicenter study including 969 ESDs for early gastric cancers, aimed to clarify the optimal intervals and duration of post-ESD follow-up by assessing the incidence of multiple cancers during follow-up, as it is known that synchronous or metachronous multiple cancers are often observed, even after an initial R0 resection. Multiple cancers were detected in 139 cases (incidence rate was 14.3 % during the mean follow-up period of 27.2 months). The cumulative recurrent rates of gastric cancer were 7.4 %, 9.5 %, and 11.5 % at 1, 2, and 3 years, respectively, with the cumulative recurrence curve displaying an inflection point at 2 months, after which there was a constant annual increase of about 3.5 % per year, not reaching a plateau for at least 5 years. In total, 10 submucosal cancers that required surgery were detected (one within 52 months after initial ESD and nine within 2 years after the procedure). It seems that early recurrence within 2 months after initial ESD may represent synchronous multiple cancers, after which metachronous lesions (treatable via ESD) may occur constantly but with a low frequency during follow-up. Therefore, it seems reasonable to perform the first esophagogastroduodenoscopy (EGD) within 3 – 6 months after ESD, followed by close controls for at least 2 years, after which follow-up should continue for at least 5 years [27].

Another factor that may also influence outcome of ESD is location of the lesion [28]. An interesting study including 1443 gastric tumors (710 early gastric cancers and 733 dysplasias) suggested that location of the tumor in the upper third of the stomach (with cardia and fundus) is associated with a significantly higher rate of incomplete resection, piecemeal resection, perforation, and a longer procedure time than lesions located distally to the upper third [28]. Technological advances of devices and instruments also influence ESD performance and are therefore welcomed by endoscopists specialized in this field. For example, the Mucosectom (Pentax, Tokyo, Japan), a new cutting device composed of a flexible plastic shaft and a cutting wire, which has been used for gastric ESD, was improved into the “Mucosectome2” by shortening its blade length (from 5 to 2.5 mm) and by making its diameter thinner than that of the conventional type. The improved device was used safely in 45 esophageal ESD cases. In fact, the new device proved safer (fewer perforations) and significantly quicker compared with 224 cases of conventional ESD [29].

Finally, another factor that might also have an impact on ESD outcome, is heparin replacement, which is often used in patients at a high risk of cerebrocardiovascular events during endoscopic interventions. This was investigated in a study from Japan, in which ESD was performed in 24 patients receiving heparin and was technically feasible, although 38 % patients experienced delayed bleeding and 4.2 % of patients had a thrombogenic event, implying that special care should be taken with such patients during ESD in order to minimize the risk of late bleeding and thrombogenic events [30].

What about EMR? Although en bloc resection rates and outcomes from EMR might be not be as impressive as those of ESD, the procedure time is shorter, complications might be less, and the learning curve seems to be reasonable with only 30 – 40 procedures necessary to reach the plateau on the learning curve. This was shown in an interesting study in which 126 esophageal endoscopic resections were performed by a single endoscopist and a single nurse, after entering a dedicated training program [31]. Moreover, EMR is not always necessarily significantly inferior to ESD. For example, its role in laterally spreading tumors was investigated in a study from Japan, in which 1249 lesions were treated by EMR and 230 by ESD [32]. En bloc resection rate for lesions > 20 mm was 27.5 % (149 /541) and 95.5 % (193 /202) for EMR and ESD, respectively, but residual tumor or recurrence was observed in only 7.8 % of the EMR group and was treated by repeat EMR. Therefore, it seems that these lesions (especially granular-type lesions, usually associated with low rates of submucosal invasion) can be treated effectively with EMR. Multiband EMR (i. e. a modified band ligator, which allows multiple piecemeal resections using the same snare without submucosal lifting or snare pre-looping, as with the traditional cap-technique) has been presented extensively in previous years as a means for piecemeal endoscopic resection in Barrett’s esophagus [33] [34]. This year, an interesting Dutch – Chinese cooperation attempted to prospectively evaluate its worth in resecting esophageal high grade intraepithelial neoplasia (HGIN) or intramucosal cancer (ESCC), which is extremely prevalent in certain high risk areas of China, where limited endoscopic expertise is available [35]. A total of 33 patients underwent the procedure. The median procedure time was 10 minutes and the median number of necessary resections was 3. Macroscopic complete resection was achieved in all lesions, at the cost of one small perforation (treated with clips). A positive deep margin was seen in one case and lymphatic infiltration in another case. Endoscopic follow-up showed HGIN at the endoscopic resection scar in two patients, which were effectively treated with argon plasma coagulation (APC).

In addition to “classical” resections in the gastrointestinal tract, endotherapy has also advanced into further areas. Per-oral endoscopic myotomy (POEM) is a method of submucosal endoscopic myotomy without skin incision. Relevant reports usually originate from Japan [36] [37], but this year interesting data from Europe were also presented [38]. POEM was performed under general anesthesia in 15 patients. Treatment success (defined as post-myotomy Eckhard score ≤ 3), was achieved in 93 % of cases (mean pre- vs. post-treatment scores: 8.9 vs. 1.5). In one patient a small mucosal perforation was suspected and clipped and in two patients an ulcer at the cardia and the esophagus occurred postoperatively. Data from this series have since been published as a full paper [39].

News from Europe regarding another interesting type of endoscopic therapy, the POSE procedure (primary obesity surgery, endoluminal), which creates transmural tissue plications in the fundus and in the distal gastric body to trigger earlier physiological feedback of fullness were also presented at UEGW 2011. Initial results from nine patients are encouraging but, of course, long-term follow-up is necessary to evaluate its real utility [40].

Finally, an Italian study, producing the first prospective long-term data regarding flexible endoscopic diverticuloscope-assisted myotomy for Zenker’s diverticulum, was presented for 35 patients. Results showed that this could be a definitive treatment for almost 50 % of patients. Once again, further analyses are warranted to identify possible prognostic factors of clinical success [41].

In conclusion, it seems that endoscopic resection is nowadays an established means of therapy, and is both effective and safe. However, innovations in techniques and various devices should be first tested in randomized studies to clarify their clinical pros and cons, as well as to calculate their possible costs, before they can be applied to everyday practice.

New sophisticated imaging methods

When comparing UEGW 2011 with previous UEGW meetings, it is noteworthy that a big part of the enthusiasm over several new advanced imaging techniques has subsided and, as a result, relevant abstracts (especially oral presentations) were fewer this year. This trend, which was also noticed last year [17], could be explained either by the logical decrease in the initial enthusiasm that usually follows the introduction of a new technique (when a plethora of abstracts and clinical trials are presented), or by the fact that data have become more robust and that the technique is being increasingly incorporated into everyday clinical practice, which is certainly the case for some of these imaging methods.

Narrow band imaging

Narrow band imaging (NBI) is one of the first contrast-enhancing techniques to be applied in endoscopy, either alone or in combination with magnification endoscopy for various indications within the gastrointestinal tract [42] [43] [44] [45] [46], but also for some pharyngeal, ampullar, and pancreatobiliary pathologies [47] [48] [49]. In most of the UEGW 2011 abstracts on NBI, the technique was combined with magnification endoscopy, which probably denotes the advantage of this combination compared with NBI alone. An interesting report from Japan used NBI with magnification endoscopy not only to diagnose superficial pharyngeal squamous cell carcinoma invading the subepithelial layer, but also as an effective means of endoscopic follow-up after endoscopic resection of these lesions (190 cases in 141 consecutive patients) [50]. Another Japanese study compared a variant of Lugol chromoendoscopy (Lugol chromoendoscopy with the pink-color sign) with NBI combined with magnification endoscopy for the early detection of superficial esophageal squamous neoplasm in a series of 275 patients with head and neck or squamous cell esophageal cancer (SCC) [51]. The pink-color sign variant had a better accuracy than “classical” Lugol chromoendoscopy, but showed no superiority compared with NBI – magnification endoscopy. In addition, the procedure with NBI – magnification endoscopy was significantly shorter.

Another interesting study attempted to improve the specificity and sensitivity of identifying high grade dysplasia (HGIN) and/or early esophageal cancer in Barrett’s esophagus by quantitative, machine-learning analyses of NBI-zoom images, using supervised machine-learning techniques to train an ensemble classifier of bagged decision trees. A total of 285 NBI images (53 with HGIN/early cancer) from 130 patients with Barrett’s esophagus were included, and histology from areas imaged was obtained and served as the gold standard. Sensitivity, specificity, and accuracy were 96 %, 94 %, and 94 %, respectively [52].

Gastric NBI (combined with magnification endoscopy, of course) was also presented at UEGW 2011. A Japanese team, presented results from a multicenter trial [53] in which previous single-center data were confirmed [54], suggesting that NBI should be added to white light imaging in order to make an accurate diagnosis of gastric small (i. e. < 10 mm) depressed lesions. This conclusion was based on the finding that the combination of NBI and magnification endoscopy was significantly superior in terms of accuracy, sensitivity, and specificity than conventional white light imaging when it came to discriminating gastric cancer from benign lesions (at a cost of prolonged examination time).

NBI cholangioscopy is presented in the section on pancreatobiliary pathologies, below.

Fujinon intelligent chromoendoscopy

Fujinon intelligent chromoendoscopy (FICE; Fujinon, Tokyo, Japan) is another contrast-enhanced technique used in upper and lower gastrointestinal endoscopy with various results [55] [56] [57]. The technique has lately also been applied in the investigation of the small bowel, combined either with balloon enteroscopy [58] or, more recently, with video capsule endoscopy (VCE) [59] [60]. This year, reports on FICE included some interesting poster presentations. A study from the UK attempted to validate a novel classification system for the in vivo diagnosis of polyps using FICE without magnification endoscopy, and demonstrated its applicability in a large prospective series with good results [61]. The same team suggested that using FICE for in vivo diagnosis of small colonic polyps in screening colonoscopy can lead to serious cost savings (€61.85 per person undergoing the examination). This could translate to a potential saving of €70136 per million population eligible for screening (i. e. €769589 annually for histology-related costs) [62].

The application of FICE in VCE is presented in the enteroscopic topics section, below.

High resolution/high definition magnifying endoscopy

High resolution, high definition or magnification endoscopy techniques have been used to improve early detection of obscure lesions in the gastrointestinal tract [63] [64]. High resolution and magnification endoscopy were presented extensively at UEGW 2011, but usually in combination with other sophisticated imaging techniques such as NBI [50] [52] [53] [54]. However, it is not always feasible to have all the latest contrast-enhanced techniques available in everyday clinical practice, and results from magnification endoscopy or high definition alone are very useful. An interesting study from Japan evaluated the use of magnification colonoscopy in the diagnosis of large serrated polyps (i. e. ≥ 10 mm) as well as in the differential diagnosis between sessile serrated adenomas and large hyperplastic polyps in a series of 220 polyps ( ≥ 10 mm) that had been completely resected endoscopically. Magnification colonoscopy was shown to help in the diagnosis of traditional serrated adenomas but did not clearly help in the differentiation between sessile serrated adenomas/polyps and large hyperplastic polyps [65]. Finally, a processor that enables resolution above high definition television standards (HD + ) in conjunction with i-Scan (a post-processing digital filter developed by Pentax) with the feature of tone enhancement, which offers a type of “digital chromoendoscopy,” helped in the detection of significantly more adenomas that had been missed by white light high defnition colonoscopy in a German study in which 40 patients underwent a tandem colonoscopy. The first examination was always a white light high definition colonoscopy with removal of all visualized polyps. The second examination was randomly assigned in a 1:1 ratio to either another white light high definition colonoscopy or high definition colonoscopy with tone enhancement [66].

Endocytoscopy and confocal laser microscopy

Endocytoscopy and confocal laser microscopy (CLM) are advanced imaging techniques that provide high resolution images in an attempt to examine endoscopic histology. Both are performed either with special probes that are advanced through working channels of standard endoscopes [67] [68] [69] or by special built-in scopes [70] [71] [72] after screening the target area with a standard endoscope (or other imaging techniques) to detect lesions of interest. Some initial disappointing results, especially in the upper gastrointestinal tract [67], resulted in a shift of research on endocytoscopy to the lower gastrointestinal tract. Although the method has successfully re-emerged in upper gastrointestinal endoscopy, based on the effectiveness of the Endocytoscopic Atypia Classification (ECA) [73], advances in colorectal endocytoscopy remain interesting.

In an intriguing prospective, randomized, non-inferiority study from Japan [74], the efficacy of integrated-type endocytoscopy was compared with conventional biopsy in the colon/rectum. A total of 102 lesions were randomly assigned to the endocytoscopy group and 101 to the biopsy group (100 and 99, respectively, completed). The diagnostic accuracy of endocytoscopy regarding its ability to differentiate between non-neoplastic and neoplastic lesions was 97.0 %, whereas that of biopsy was 99.0 %, which was definitely within the non-inferiority margin (absolute difference – 2.0 %, 95 % confidence interval – 6.9 % to 2.9 %). Another Japanese study demonstrated that endocytoscopy could be a superior predictor of the malignant potential of colorectal lateral spreading tumors compared with magnification endoscopy. From a series of 9079 resected early colorectal cancers, 309 were observed by endocytoscopy and magnification endoscopy and 82 lateral spreading tumors were classified using the integrated-type endocytoscope and Kudo’s pit pattern classification. Endocytoscopy proved to be superior to magnification endoscopy, showing an excellent agreement with histopathology and a positive likelihood ratio for submucosal invasion of 3.73, whereas that of magnification endoscopy was 2.52 [75].

CLM applications, especially for lower gastrointestinal disorders, retained a high level of interest at UEGW 2011. Two interesting French studies focused on the help probe-based CLM can provide in establishing differentiation criteria between hyperplastic polyps and serrated adenomas. The first study attempted to define morphological criteria of differentiation from elements of the colonic mucosal architecture. A total of 120 probe-based CLM sequences acquired from a series of 10 serrated adenomas and 26 hyperplastic polyps during 26 total colonoscopies were retrospectively reviewed. Focus was centered on glandular criteria, goblet cells distribution, and general epithelial relief. Description of sinuous folds on the epithelial surface, with a spotted aspect due to a high density of mucus-secreting goblet cells and presence of tortuous glands, with variable sizes and indefinite lumens were considered signs of serrated adenomas [76]. These retrospective data were prospectively validated in the second study by obtaining 41 sequences accounting for 11 serrated adenomas, acquired during eight colonoscopies with EMR. Indeed, the aforementioned criteria seem to differentiate hyperplastic polyps and serrated adenomas but their performance characteristics and predictive values need to be confirmed [77].

CLM in the upper gastrointestinal tract also received some attention within the oral presentations at UEGW 2011. An interesting multicenter international study attempted to assess the interobserver agreement and accuracy within a panel of gastroenterologists and pathologists (three experienced CLM endoscopists, one experienced CLM pathologist, and two novice CLM pathologists) in the diagnosis of neoplasia in Barrett’s esophagus. A total of 79 endoscope-based CLM images from biopsy-matched sites (including 16 cases with neoplasia i. e. dysplasia or carcinoma) were reviewed in order to distinguish neoplastic vs. non-neoplastic patterns. Interobserver agreement among endoscopists and pathologists was 0.82 and 0.70, respectively. Accuracy, sensitivity, and specificity were 98.7 %, 93.7 %, and 100 % for gastroenterologists, 93.7 %, 75.1 %, and 98.4 % for all pathologists, and 94.9 %, 81.25 %, and 98.4 % for the expert pathologist, respectively.

These data might suggest that confirmation of CLM images by a pathologist with expertise in their interpretation might be an adjunct to classical biopsies [78]. But how quickly can an endoscopist start to interpret CLM? Pretty fast, according to a Dutch study that aimed to determine the learning curve of endoscope-based CLM and assess its diagnostic accuracy and intra- and inter-observer agreement using three endoscopists without previous training in CLM image interpretation. After a short induction “training” session with 10 images, endoscopists were given a set of 90 images to evaluate. After each set of 30 images, the accuracy of each observer was assessed and each image that was inaccurately scored was discussed. The procedure was repeated 6 months later with the same images, shown in a different order. During the initial assessment, the accuracy of each endoscopist was 85.6 %, 94.4 %, and 92.2 %, respectively. Accuracy remained high during the first assessment for all three observers, without significant changes between the first 30 images and the second or between the first set and the last 30 images. At 6 months later, the accuracy for each observer remained high (88.9 %, 90.0 %, and 88.9 %). Kappa values for the intra-observer agreement were 0.68, 0.84, and 0.77 for each observer, and the inter-observer agreement was 0.73 during the first assessment and 0.72 during the second assessment [79].

Applications of CLM in pancreatobiliary pathologies are presented later in this report.

Autofluorescence imaging

“Red flag” endoscopic techniques are special methods that when added to standard white light endoscopy can increase the sensitivity for detection of early neoplasia in a broad field imaging examination [80]. Autofluorescence imaging (AFI) is considered to be one of the most promising techniques for upper as well as lower gastrointestinal endoscopy [81] [82] [83]. Interestingly, at last year’s congress, most of the abstracts on AFI were focused on its applications in the colon [17]. This year, however, as well as the “classical” topics on colorectal AFI, there was also a “return” to studies in the upper gastrointestinal tract, which highlighted the fact that image interpretation in AFI remains problematic. In a study from the UK, 74 sets of images were prospectively collected from 63 patients. AFI and “plain” high resolution images were presented to three AFI expert and three non-expert endoscopists, followed by high resolution and AFI images from corresponding pathological areas. Images were scored by the endoscopists and the inter-observer agreement in detecting dysplastic lesions and accuracy was calculated (histology served as the gold standard). Inter-observer agreement for dysplasia using AFI alone was only fair to moderate among endoscopists (kappa value for experts 0.39; non-experts 0.26), which significantly improved when corresponding high resolution images were also shown (0.57 and 0.47, respectively). There was a significant difference in inter-observer agreement between experts and non-experts, which suggests a learning curve, whereas the overall accuracies for diagnosis of dysplasia with AFI were reasonable [84]. The limitations of the method were also further confirmed in a large multicenter study from Japan [85], which contradicted a previous single-center report showing that AFI was useful for the detection of colon polyps compared with standard white light colonoscopy [86]. Here, 550 patients were enrolled (542 eligible for analysis) and it was shown that adenomatous lesions in the right-sided colon were more frequently detected with standard colonoscopy than with AFI. It seems that a better definition of what constitutes an AFI-positive signal or a better standardization of the technique is necessary in order to improve the effectiveness of AFI, as it has been around for several years now and should finally start to show better results.

Barrett’s esophagus

Barrett’s esophagus is the “classical” topic where various endoscopic procedures and techniques might overlap and cooperate to facilitate diagnosis and therapy. Therefore, the abstracts relevant to this topic might also overlap or be presented elsewhere in this report [52] [78]. It has been shown that Barrett’s esophagus with focal lesions containing HGIN or early cancer can be treated by radiofrequency ablation (RFA) with prior endoscopic resection [87] [88] [89]. However, there is a lack of large, multicenter trials to verify this approach. This deficiency was addressed in an interesting prospective study that included 130 patients with Barrett’s esophagus and HGIN/early cancer ( ≤ 12cm; median Barrett’s esophagus was C3M6) from 12 European expert centers [90]. Endoscopic resection (followed by RFA) was performed for focal lesions < 2 cm and < 50 % circumference. RFA was performed at 0, 3, 6, 9, and 12 months (maximum two circumferential and three focal treatments). Investigators were trained at the coordinating site and the first four RFAs were supervised by the principal investigator. A coordinating team attended all treatments and the first follow-up at each site. Histology was reviewed at the coordinating site. Up to abstract submission, 11 patients were still being treated and 5 had dropped-out due to unrelated reasons. Intention-to-treat analysis showed that complete eradication of intestinal metaplasia and neoplasia was reached in 108 /119 (91 %) and 114 /119 (96 %) patients, respectively. For the per-protocol analysis, the respective results were 108 /114 (95 %) and 114 /114 (100 %) of patients. Rescue endoscopic resection (allowed by the protocol) for suspicious lesions found during treatment was performed in three patients and for residual Barrett’s esophagus after RFA in four patients. Adverse events (superficial mucosal lacerations at an endoscopic resection scar or proximal reflux stenosis) during RFA were all “mild,” and occurred in 10 % of patients. Therefore, it seems that this approach is effective and safe when performed by trained endoscopists in carefully selected patients.

Another interesting study from The Netherlands, involving 2 of the 12 expert European centers from the previous abstract, supported the long term effectiveness of this therapeutic strategy by reporting 5-year follow-up data of a prospective cohort of 23 patients with Barrett’s esophagus and HGIN or early cancer, all of whom achieved complete epithelial reversion 1 year after RFA [91]. Of the 23 patients, 13 underwent endoscopic resection prior to RFA. All patients were free from neoplasia or intestinal metaplasia at 1 year (2 after focal rescue endoscopic resection). Four patients dropped out for unrelated causes (they were also disease-free at the time of drop-out). Sustained eradication of neoplasia and intestinal metaplasia occurred in 100 % at 5-years follow-up and no buried glands were observed. An alternative approach was followed in a Dutch series of 24 patients (from 3 of the 12 expert centers above [90]) [92]. Here, the length of pre-RFA endoscopic resection was limited to < 2 cm and < 50 % of the circumference to avoid the negative impact of endoscopic resection-related scarring after extensive endoscopic resection, which challenges circumferential RFA (cRFA). However, in selected cases, more extensive endoscopic resection is required and a combination (cRFA with endoscopic resection in the same session) was tested as a means to avoid endoscopic resection-related scarring. The results showed that the combined approach is feasible (all cases were successful) with an acceptable complication rate (one perforation, four bleedings, and four stenoses, all managed endoscopically).

Favorable long term outcomes from endoscopic resection alone were also observed in a German series of 953 patients with Barrett’s esophagus (454 with short-segment and 499 with long-segment Barrett’s esophagus). A total of 2399 endoscopic resections were performed (mean 2.5 /patient). Complete remission of neoplasia was achieved in 907 /953 patients (95 %), and 84 died from causes unrelated to the tumor. Recurrence or metachronous neoplasia was observed in 112 /907 patients (12 %) but endoscopic re-treatment was successful in 103 /112 (92 %). Long term complete remission was 94 % [93].

The rationale behind endoscopic resection or RFA of Barrett’s esophagus is that the latter is considered the most important risk factor for developing esophageal adenocarcinoma, but the risk (considered to be 0.5 %/year) is based on small and potentially biased studies. In an interesting abstract from Denmark [94], followed by the full publication [95], this risk was found to be five times smaller, with dysplasia at index endoscopy being a robust risk identifier. This might affect the current extensive surveillance programs (which are based on these high risk estimates) or alter indications of endotherapy, which is not completely free of risks or side effects [96]. Perhaps in the future, other non-invasive therapies such as chemoprevention [97] [98] might have a role in the treatment of patients with Barrett’s esophagus with low or intermediate risk for progression to adenocarcinoma, and the invasive treatment modalities might be reserved for those at a high risk.

Gastrointestinal bleeding

Gastrointestinal bleeding and its treatment is an important field for gastrointestinal endoscopy research, as it is an area where technical advances can be implemented into everyday clinical practice. Compared with previous meetings, UEGW 2011 had fewer endoscopy-related abstracts. The most interesting endoscopic report referred to the application of a hemostatic matrix (Floseal; Baxter Healthcare Corp., Deerfield, Illinois, USA). This substance has been used for some time in surgery for quick and effective hemostasis. It consists of two compounds, a gelatin matrix and human thrombin, but because it is thick and viscous, it could not be injected through standard endoscopic needles or catheters. Recently, a new system has been developed, consisting of a 7-Fr catheter (loaded with the hemostatic matrix) and a balloon, which is inserted into the catheter and is used to deploy the matrix on the bleeding site and keep it in place until hemostasis is achieved. According to a report from Italy, the system allows delivery of the product resulting in effective hemostasis. Hemostasis was confirmed by a second-look endoscopy, which was performed routinely after 36 – 48 hours [99].

New hemostatic tools are generally welcomed but until they can be applied in everyday practice, improvements to “standard” methods, including clips, are extremely important. The “Over-the-Scope Clip” (OTSC; Ovesco, Tübingen, Germany) has been presented at previous UEGW congresses, mostly but not exclusively as a tool for closure after natural orifice transluminal endoscopic surgery (NOTES) [17] [100]. Published data on the effectiveness of the clip in gastrointestinal bleeding are limited. Outcomes from a German series of 24 patients (28 OTSCs) treated for gastrointestinal emergencies (15 bleedings) have been reported [101]. Overall success was 19 /24 (79 %), but 3 /15 patients with life-threatening upper gastrointestinal bleeding died due to hemorrage (one even after additional surgery). Therefore, although promising, further clinical experience will help to identify the optimal role and indication for OTSCs in gastrointestinal bleeding.

Another alternative for endoscopic hemostasis, namely endoscopic ultrasound (EUS)-guided vascular therapy (embolization), could be used before radiological-guided vascular intervention or surgery. A French series of eight patients with upper gastrointestinal bleeding was presented at UEGW 2011 [102]. The bleeding vessel was punctured under Doppler control by a 19-G needle, followed by injection of a sclerotic agent. The procedure was efficient in 7 /8 patients (85 %) in one session (only one required a second intervention). No complications were observed. These new developments, together with a new hemostatic nanopowder recently reported [103] [104], are all welcomed, as they might improve the success of endoscopic hemostasis, at a time when the profile of gastrointestinal bleeding is changing [105] and the overall burden of illness seems to be an independent predictor of bleeding in addition to the known risk factors of diseases and medications [106].

Enteroscopy topics

The most advanced modalities in the imaging of the small bowel are video capsule endoscopy (VCE), the deep enteroscopy techniques (also known as push-and-pull enteroscopy) of double- and single-balloon enteroscopy (DBE and SBE, respectively), and, most recently, enteroscopy with a spiral overtube (spiral enteroscopy) [107] [108] [109] [110]. The initial enthusiasm over deep enteroscopy was not evident at this year’s meeting. Only a few poster presentations (mostly on DBE) were presented, which probably indicates that these methods have passed from “novel” and “experimental” to everyday methods. However, some interesting abstracts on VCE were presented at UEGW. A recent advancement in VCE is the development of devices that allow capsule steering by external low magnetic fields [111]. Initial data were presented at last year’s meeting [17]. The magnetically guided capsule contains two cameras at its ends and the magnetic fields allow movement in five mechanical degrees of freedom. The important differences to conventional gastroscopy are the newly developed control and movement concept based on the five degrees of freedom, unrestricted changes in patient position, and the absence of the endoscope tube that can block a view. These principles allow the system to provide viewing angles that give new perspectives on the anatomy of the stomach. Reaching a certain position with the capsule was reproducible using the new control and movement concept [112].

The first small-bowel capsule was PillCam SB (Given Imaging, Yoqneam, Israel), which was followed some years later by other capsule types, including the EndoCapsule system (Olympus Medical Systems Corp., Tokyo, Japan) and the MiroCam (Intromedic, Seoul, Korea). An Austrian study prospectively compared the latter two devices, regarding successful ileocecal visualization and diagnostic yield. A total of 76 patients were included and patients swallowed both capsules in a randomized order with an interval of 2 hours between. Videos were analyzed separately in a crossover manner by two well experienced blinded examiners, who re-evaluated any discordant capsule pairs together to achieve consensus on the final diagnoses. In total, 48 /50 MiroCam (96 %) and 45 /50 EndoCapsule (90 %; P = 0.18) examinations achieved successful ileocoecal visualization. Moreover, both capsules showed equivalent diagnostic yield (MiroCam 35 diagnoses in 25 /50 cases; EndoCapsule 29 diagnoses in 24 /50). Concordant findings were observed in 34 /50 cases (kappa = 0.50; P < 0.01); nine discordant cases were classified normal by one capsule and pathological by the other and in seven cases the entity or amount of pathologies differed [113]. These interesting findings should be taken into account, especially in cases where VCE examination is normal, but the patients’ problems persist.

Another interesting field for capsule endoscopy is visualization of the colon. A prospective study conducted in 17 public or private French endoscopy centers (107 patients) attempted to assess the diagnostic yield of VCE in patients with incomplete colonoscopies or who had temporary contraindication due to cardiovascular disease precluding anesthesia [114]. Diagnostic yield of the colon capsule was defined by identification of a colorectal lesion that either directly explained the patient’s symptoms or necessitated a diagnostic or therapeutic examination. Final diagnoses and outcomes were evaluated at 6 and 12 months. The examination was incomplete in 7 /107 cases (six retentions, one recording failure). Therefore, 100 patients had a complete examination. Overall diagnostic yield was 36 %, and diagnostic yield for indication was 31.6 % (12 /38) in patients undergoing screening VCE and 38.7 % (24 /62) in patients with symptoms. Intention-to-treat analysis yielded positive results in 33.9 %. Follow-up was available for 95 patients. Of 36 patients with positive findings 19 (52.8 %) underwent a complementary therapy. For patients with a negative colon capsule examination, nine underwent a complementary procedure (colonoscopy [n = 6], virtual colonoscopy [n = 3]) with one patient showing diminutive adenomas. No new colorectal cancers were diagnosed during follow-up. These results stress the usefulness of colon capsule in cases of colonoscopy failure, due to its high diagnostic yield and therapeutic impact, and are in line with previous results reported at last year’s congress [115].

Another interesting indication for the colon capsule is the differentiation of active from inactive ulcerative colitis, as mucosal healing is now considered an important factor in the monitoring of therapy. This was investigated in an Asian multicenter international study in which 96 patients with known ulcerative colitis underwent colon capsule endoscopy to assess mucosal inflammation, with standard colonoscopy serving as the gold standard. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) for active inflammation were 89 %, 75 %, 93 %, and 65 %, respectively [116].

Improvements to “regular” VCE were also discussed at UEGW 2011. For example, the “Contrast Capsule” (Olympus EC Type 1) is equipped with a selected white light-emitting diode (LED), which enhances imaging of mucosal vascularity. The device was tested in 22 patients with obscure gastrointestinal bleeding to evaluate whether the contrast image improves visibility of small-bowel lesions. Two blinded endoscopists evaluated both white light and contrast images. Addition of the contrast feature resulted in improved visibility of small-bowel lesions in 15 /20 patients (75 %), equivalent visibility in 4 /20 (20 %), and decreased visibility in 1 /20 (5 %). Inter- and intra-observer kappa values were 0.57 and 0.78, respectively [117].

Similar features, including the “blue mode” (included in the panel of image enhancement buttons of the RAPID software), as well as FICE (F1, wavelength red 595, green 540, blue 535 nm) were also shown to be helpful in improving the imaging of the small bowel and detection of small-bowel pathologies in some poster presentations [118] [119].

Colonoscopy topics

Screening and surveillance colonoscopy for colorectal cancer (CRC) are considered pivotal fields of interest for endoscopists [120] and are the focus of many studies presented each year at UEGW. Among factors that contribute to an appropriate level of quality in colonoscopy is sedation. Propofol is considered by many to be the preferred medication [121] but it is not uniformly utilized [122] and requires various measures in order to be given with safety [123]. Standard monitoring during colonoscopy includes pulse oximetry, automated blood pressure readings, and electrocardiography in patients with cardiac disease. However, a German randomized controlled study suggested that additional capnographic monitoring reduces the incidence of arterial oxygen desaturation during propofol administration. A total of 760 patients scheduled for colonoscopy under propofol were enrolled at three centers. Patients were randomly assigned to either standard monitoring or to additional capnography. Intention-to-treat analysis revealed a significant reduction in the incidence of oxygen desaturation in the capnography group (38.9 % vs. 52.9 %) and the numbers of patients with a fall in oxygen saturation < 90 % and ≤ 85 % were also in favor of capnography (12 % vs. 17.6 % and 3.7 % vs. 7.5 %, respectively) [124].

Although sedation administration is the mainstay of screening colonoscopy, attempts to achieve unsedated colonoscopy are also noteworthy. The Wiesbaden group randomized 116 patients who agreed to start colonoscopy without sedation into two groups: one with water infusion (which enhances cecal intubation), the other with air insufflation. Sedation and analgesia were offered on demand. The water method significantly improved tolerance (8.6 % requested medication vs. 34.5 % in the air group) but did not increase unsedated complete colonoscopies, as suboptimal preparation reduced visibility [125].

Failure of cecal intubation limits colonoscopy as a screening tool. Even experienced colonoscopists might fail to reach the cecum in about 2 – 10 % of examinations. Various methods to reach this landmark are used, including the use of magnetic endoscope imaging and lately the DBE (standard or in a short version), or applying a transparent cap to the tip of the scope, known as “hood-assisted colonoscopy” [126]. These techniques were presented in some abstracts at UEGW 2011. In an interim analysis of the first prospective randomized trial comparing colonoscopy and standard DBE with conventional colonoscopy, 28 patients were recruited (16 with DBE) [127]. The mean pre-procedure difficulty scores and cecal intubation times were similar for both groups but mean patient discomfort and pain scores were significantly lower for DBE (2.3 vs. 5.9 and 1.9 vs. 6.0, respectively). Median sedation dose and recovery times were significantly less for DBE (5 vs. 30 minutes). Examiners and patients found DBE significantly easier to perform (median difficulty score 3.6 vs. 6.3) and more satisfying (median Likert satisfaction score 5 vs. 3.5). All DBE patients said they would undergo the procedure again, whereas 58 % of the conventional colonoscopy group would consider an alternative procedure [127].

In a study from Japan, results from the first multicenter prospective trial of total colonoscopy using a short DBE scope were presented for 110 patients with previous incomplete colonoscopy. Cecal intubation was achieved in 100 % (median time 12 minutes, range 4 – 47 minutes). Pain was rated as none, slight, or tolerable (occurring in 50.9 %, 31.8 %, and 17.3 %, respectively), and 96.4 % of patients stated that this examination was more comfortable than the previous colonoscopy [128].

Finally in an Italian multicenter randomized controlled trial, cecal intubation rates and times, number of attempts to intubate the ileocecal valve, and polyp detection rates with hood-assisted colonoscopy (n = 179 patients) among trainee endoscopists were compared with those of standard colonoscopy (n = 199). Cecal intubation was achieved in significantly more patients undergoing hood-assisted colonoscopy than with the standard technique (170 /179 vs. 184 /199). Hood-assisted colonoscopy mean cecal intubation times were significantly less than standard colonoscopy (4.41 ± 1.85 minutes vs. 7.30 ± 3.50 minutes), as was the number of attempts for ileocecal valve intubation (2.1 ± 0.89 vs. 4.57 ± 2.25). Finally, overall polyp detection rates were higher for hood-assisted colonoscopy (0.90 vs. 0.71), as were the rates for polyps > 0.5 mm and < 1 cm [129]. These results are in line with others that consider hood-assisted colonoscopy to be more effective in adenoma detection than even sophisticated imaging techniques [130].

The effect of colonic contractility on polyp detection is another factor that might influence quality of a colonoscopy but this characteristic has not been studied adequately to date [131]. A large, blinded, placebo-controlled trial from Australia suggested that hyoscine butylbromide (20 mg intravenously when the cecum is reached) aids in polyp detection. Hyoscine administration increased the number of polyps found per patient (0.90 vs. 0.74 in the placebo group; P = 0.02), but other factors, including age and depth of scope insertion at the cecum were also independent predictors of polyp detection [132], so more research in this area is needed before these results can be extrapolated.

Another issue influencing CRC screening programs is the burden and costs associated with resection of small polyps. There is a trend to replace – if possible – standard histology with optical diagnosis using advanced imaging methods (e. g. white light magnification endoscopy and NBI), which could distinguish adenomatous from non-adenomatous diminutive polyps ( < 10 mm) and set surveillance intervals [133]. An interim analysis from an Italian study [134] attempted to evaluate the appropriateness of an “endoscopy-based” surveillance strategy compared with a “histology-based” strategy after resection of diminutive polyps. A total of 168 consecutive outpatients with polyp(s) (exclusively < 10 mm) were included. After an NBI training session, expert endoscopists were asked to predict whether resected polyps were adenomatous or not, based on a combination of magnification endoscopy with NBI, and to assign a colonoscopy surveillance interval. Pathology was the reference standard. The number of diminutive polyps was 309 (211 adenomas, 5 of which [2.4 %] had advanced histology). Sensitivity and specificity of endoscopy in predicting adenomas were 84.8 % and 73.5 %, respectively, but the accordance of endoscopy- and histology-directed surveillance was 77.4 % (i. e. negatively affected by misclassification of small adenomas as hyperplastic lesions). Although the prevalence of advanced histology in diminutive polyps is low, improvement of optical polyp discrimination is still needed before surveillance can be decided according to endoscopy alone.

Finally, although it is generally perceived that computed tomography (CT) colonography is less burdensome than colonoscopy for primary CRC screening [135], prospective randomized comparative data are lacking. In a large Dutch study, expected and perceived burden of screening was investigated in 8844 individuals who were randomly selected and invited to undergo colonoscopy (n = 5924) or CT colonography (n = 2920) [136]. Individuals were asked to complete a questionnaire on expected burden (completed by 36 % of the colonoscopy group and 41 % of the CT colonography group); 1009 /1276 colonoscopy (79 %) and 801 /982 CT colonography (82 %) participants also completed a questionnaire on perceived burden. Colonoscopy participants expected the screening procedure and bowel preparation to be more burdensome compared with participants undergoing CT colonography. Participants perceived CT colonography to be more burdensome than colonoscopy. Intended participation in the next screening round was comparable between the groups.

Two other abstracts presented data on therapeutic issues. A multicenter retrospective study (43 patients) reported on the effectiveness of fully covered metallic stents for benign colonic strictures [137]. Insertion was successful in all cases without complications but clinical success was moderate (relief of symptoms in 34 /43 patients). There was a high rate (27 /43 patients) of spontaneous migration in the first 3 months especially when stent diameter was < 20 mm, but only one impaction required surgery. Retrieval of non-migrated stents was easy. Recurrence of obstruction occurred in 22 /43 patients but the remaining 21 were recurrence-free during follow-up. Predictive factors of recurrence or efficacy were not identified.

Finally, a prospective study from Spain questioned the prophylactic use of hemoclips to prevent post-polypectomy bleeding and perforation in large pedunculated polyps. A total of 101 patients were randomized, 3 were excluded, and 35 refused to participate. An unexpected increase in morbidity in the hemoclip-before group, resulted in early suspension of the trial, as the prophylactic use of hemoclips in polypectomies actually led to a further inacceptable risk of mucosal burns and perforation and did not reduce the risk of bleeding [138].

Endoscopic retrograde cholangiopancreatography and pancreatobiliary topics

As in previous years, interest in pancreatobiliary endoscopy remained high at this year’s meeting. For example, intrabiliary NBI and CLM are intriguing new fields that attract scientific and clinical interest. NBI cholangioscopy might be helpful for the accurate diagnosis and staging of minute bile duct tumors (especially mucin-hypersecreting lesions), as the NBI function can help the endoscopist to see through the mucin. This was demonstrated in an interesting video case from Korea [139]. Percutaneous transhepatic biliary drainage was initially performed, the tract was then dilated up to 16 or 18Fr, and some days later cholangioscopy was performed using an ultrathin ureteroscope (Olympus CYF240A). Initially, white light imaging was chosen and then the same biliary tree was evaluated using NBI. CLM has also been applied in the bile duct. A group from France, with experience in the field [140], reported their data from a bicentric study, where optical biopsies were compared with standard histology [141]. A total of 46 patients with biliary stenosis requiring biliary drainage underwent endoscopic retrograde cholangiopancreatography (ERCP) and intraductal CLM. The CLM miniprobe was introduced through a catheter, which was placed in the biliary duct over a 0.035-inch guide wire (depth of penetration was 20 microns and magnification was × 400). The results showed that the technique is a promising one, with a sensitivity of 90 % and specificity of 62 %. However, diagnostic criteria need to be defined more accurately and image quality requires improvement.

Peroral cholangioscopy has gained new attention since the advent of a new single-operator instrument with improved handling, compatibility with electrohydraulic lithotripsy, and ability to take biopsy samples (SpyGlass; Boston Scientific, Natick, Massachusetts, USA). After its initial use as an imaging tool, it has now been applied for tissue diagnosis and therapy [142] [143] [144]. Its contribution to the diagnosis of intermediate biliary strictures was confirmed in an Italian study of 51 patients. The diagnoses obtained by direct visualization of strictures and targeted biopsies were recorded and compared with brushing biopsies, surgical histology (when available), and/or clinical follow-up. Insertion of the SpyGlass into the common bile duct (CBD) and stricture inspection was achieved in all cases and allowed targeted biopsies in 45 /49 (pushing the forceps was impossible in the remaining 4). Specimens suitable for histology were obtained from 39 /44 cases. Accuracy was 85 % compared with 44 % for standard brushing sampling, and the diagnosis resulted in a change to the therapeutic management in 26 /49 patients [145].

The therapeutic properties of the SpyGlass system were also presented in a study from India, in which 64 patients with large (n = 52) or impacted (n = 8) biliary stones, as well as 4 patients with impacted pancreatic ductal stones not amenable to standard extraction, underwent stone fragmentation with a Holmium laser using the SpyGlass system. The Holmium laser achieved successful fragmentation of stones in all patients (50 /64 complete clearance after one session) at a small cost of time (mean 45.9 minutes) and complications (8 of 70 patient procedures) [146].

Finally, a novel direct transnasal cholangioscopy technique using an ultra-slim high resolution endoscope with an intraductal balloon to maintain biliary access without previous placement of a guide wire was presented in a feasibility study from Germany. A total of 44 patients with biliary disease and previous sphincterotomy underwent 50 direct transnasal cholangioscopies (39 /50 procedures were successful in a mean 13.1 ± 8.1 minutes). Intraductal biopsies under direct visualization were taken from 16 lesions, and 16 patients underwent therapeutic interventions including APC, laser lithotripsy, and stone extraction. This technique seems attractive and if incorporated into routine use could expand the use of cholangioscopy to non-specialized centers [147].

Some “classical” ERCP topics related to therapeutic issues were also presented at UEGW 2011. An interesting meta-analysis examined the pooled efficacy and complications associated with limited endoscopic sphincterotomy (EST) followed by large balloon dilation of the ampulla, in order to extract large bile duct stones. The technique is useful when either the distal CBD is tapered (precluding extraction of large stones), or in cases of a periampullary diverticulum, where extended EST may not be possible [148] [149]. A total of 14 studies were identified (967 patients, 1070 procedures) with significant heterogeneity. Pooled efficacy of duct clearance at the first attempt was 90 % and complete duct clearance was 96 %. Pancreatitis occurred in 4.6 %, bleeding in 4 %, cholangitis in 1.4 %, and perforation in 1.1 %; lithotripsy was performed in 9.2 % of cases. These results suggest that the technique is effective with complication rates comparable to conventional EST [150]. Another interesting study related to everyday ERCP practice was conducted in Italy. A total of 78 patients (all poor surgical candidates) were treated with biliary stenting due to failed stone clearance and were randomized into two groups, the first one (n = 39) being assigned to stent change every 3 months (or less if symptoms appeared) and the other to change on demand according to symptoms. The difference in acute cholangitis (3 patients vs. 14, P = 0.030, with 1 vs. 3 deaths, respectively) suggests that the best management to avoid cholangitis is stent change at determinate intervals (3 months according to the authors’ experience) [151].

Another interesting study covering 6 years’ experience in endoscopic treatment of pseudocysts (120 patients) was presented. In addition to cyst drainage, duct decompression was also necessary in order to achieve optimum management of the pseudocysts [152]. Another interesting ERCP-related topic was tackled by a study from Sweden in which GallRiks, the Web-based Swedish Registry for Gallstone Surgery and ERCP was used in order to investigate whether the frequency of post-ERCP pancreatitis (PEP) is increased or not in patients with primary sclerosing cholangitis (PSC) [153]. A total of 204 ERCPs (159 patients) with the indication “suspicion of PSC” in GallRiks were assessed. The rate of overall post-ERCP complications was 19 %, significantly higher than in patients without PSC (11 %; P = 0.0011). PEP was also more than twice as common in patients with PSC (7 % vs. 3 %; P = 0.0054), suggesting that PSC may be a risk factor for PEP. Another study from Finland attempted to find risk factors for PEP in patients with PSC. A total of 441 ERCPs with PSC as the indication were analyzed. PEP occurred in 7.0 % (mostly mild cases), and predicting factors were female sex (odds ratio [OR] 2.6; P = 0.015) and placement of the guide wire in the pancreatic duct (i. e. difficulty in cannulation [OR 8.2; P < 0.01]). Previous biliary EST was a protective factor (OR 0.23; P = 0.01) [154].

Endoscopic snare papillectomy (ESP) is the standard of care for ampullary adenomas and in situ carcinomas, with pancreaticoduodenectomy indicated for invasive cancers. An Italian study evaluated ESP for early invasive cancers of the papilla of Vater. During a 9-year period, 25 patients with invasive adenocarcinomas limited to the papilla underwent ESP followed by additional pancreaticoduodenectomy or follow-up in patients unfit for surgery [155]. The results suggest that surgery is a better treatment, but ESP can also be curative in some patients with invasive cancer, and should therefore be considered for patients with small ampullary cancers who are unfit for surgery.

Endoscopic ultrasonography

In recent years EUS has become established not only as an important diagnostic tool but also as a basic means of therapy [156]. One of the latest advances offered by EUS is endosonographic cholangiopancreatography (ESCP), which is an alternative for drainage of the bile duct in cases of failed ERCP [157] [158]. The advantage of this method is that it can be performed in a single session with ERCP without the need for external drains. A 10-year international (six centers) experience of ESCP performed on 240 patients was analyzed retrospectively and presented at UEGW [159]. The intrahepatic approach (transgastric) was used in 60 % of patients, without significant difference in technical success compared with the extrahepatic route in benign obstruction but with significantly higher success rates for malignant obstruction (83.8 % vs. 94.9 %; P = 0.01). Technical success was achieved in 87 % overall and was significantly higher for malignant obstruction (90.2 %) than for benign obstruction (77.3 %). Metal stents were placed in 60 % of benign and 95 % of malignant cases and plastic stents were placed in 27 % and 70 %, respectively. Complications were similar for extra- and intrahepatic approaches and for benign and malignant etiologies and included pneumoperitoneum (5 %), bleeding (11 %), bile leak/peritonitis (10 %), and cholangitis (5 %) with four deaths (one bile peritonitis, one perforation, and two bleeding).

Outcomes of EUS-guided choledochoduodenostomy (n = 21 patients) and hepatogastrostomy (n = 12) were retrospectively analyzed in a study from Japan [160]. The technical success of choledochoduodenostomy was 100 %, including a rendezvous procedure with ERCP, with seven complications (peritonitis [n = 5] and cholangitis [n = 2]). For hepatogastrostomy, technical success was 100 % (with one rendezvous procedure), functional success was 83.3 % (10 /12), and there were seven complications (peritonitis [n = 4], cholangitis [n = 1], and stent migration [n = 2]), suggesting that the method is a feasible salvage treatment for biliary decompression if transpapillary drainage is unsuccessful [160].

Finally, data from a large series of 4362 therapeutic ERCPs from India, of which 144 (3.3 %) required precut papillotomy, were compared with data from 58 patients who underwent EUS-guided rendezvous procedure due to distal CBD obstruction. Of the 144 precut cases 138 (95.8 %) were successful, and results were similar in the EUS-guided rendezvous group (57 /58 cases [98.3 %]). There were six failures in the precut group, whereas the one failure in the EUS group was due to inability to pass the guide wire across the stricture of a pancreatic head cancer. There was no significant difference among the precut group and the EUS group in terms of overall complications, pancreatitis or bleeding [161].

Another therapeutic application of endosonography is EUS-guided RFA [162]. Although some experience has been gained for treatment of hepatic metastases by percutaneous RFA, EUS seems to be an essential tool for delivery of RFA in pancreatic lesions. In a Korean study, RFA was performed using bovine liver to optimize the characteristics of the delivery system and instruments, before being used in vivo where EUS-guided RFA was performed on the pancreas of 10 adult mini-pigs. EUS-guided RFA was technically feasible and effective, without serious complications and could therefore have therapeutic potential for human pancreatic tumors [163].

Other, more “classical” EUS-related topics were also reported at UEGW 2011. The short- and mid-term risk of malignant evolution is well described in branch duct intraductal papillary mucinous neoplasms (BD – IPMNs); however, few data beyond 5 years are available. An interesting study including 53 consecutive patients with BD – IPMN and follow-up of > 5 years assessed this risk [164]. Follow-up was performed with CT, magnetic resonance cholangiopancreatographies (every 1 or 2 years), and EUS alone or with fine-needle aspiration (EUS – FNA) in case of doubt. Invasive carcinoma occurred in two patients, both after 7 years of follow-up and less than 12 months after an imaging procedure, questioning current surveillance strategies and raising the indication for earlier surgery [165].

An interesting prospective study including 123 patients who underwent EUS – FNA (56 for suspicious mediastinal lymph nodes or masses, 46 for pancreatobiliary disease, and 21 for other indications, mostly submucosal masses) [166] confirmed the well-known fact [167] that core biopsies can be reliably obtained at EUS using a 22-G needle and provide a pathological diagnosis more frequently than cytology (95 % vs. 87 % in mediastinal, 78 % vs. 68 % in pancreatobiliary, and 81 % vs. 71 % in other samples). Both cytology plus histology added only 3 % to the diagnostic results of histology alone.

After relative silence for some years, a long-awaited advancement in EUS – FNA needles was reported at UEGW. A total of 96 consecutive patients, who underwent EUS – FNA for solid pancreatic masses, were prospectively included. Biopsies were obtained by the new needle (19G or 22G; Echotip Procore; Cook Medical Inc., Limerick, Ireland), whereas cytology samples were acquired with standard 22G or 25G needles. Diagnosis was correct in 45 patients (95.7 %) with the new needles (22 /23 with 22G and 23 /24 with 19G) vs. 40 correct diagnoses (81.6 %) with the standard needles (19 /24 with 22 G and 21 /25 with 25 G) (P = 0.03) [168].

Other interesting EUS-topics that were presented included the excellent results from the largest European cohort of intraductal ultrasound for the diagnosis of bile duct strictures [169], the promising data from the first multicenter prospective study regarding contrast-enhanced harmonic ultrasound (CEH – EUS) in the diagnosis of pancreatic cancer [170], and two reports showing promising results of EUS-guided intratumoral CLM (a feasibility study and interim results from an international prospective multicenter study regarding pancreatic cystic tumors) [171] [172]. An interesting French – Irish cooperation assessed the role of EUS-imaging in the diagnosis of autoimmune pancreatitis and concluded that “ductitis” (irregular main pancreatic duct with succession of narrowed/normal or dilated segments), hyperechoic thickening of the main pancreatic duct wall and hypoechoic thickening of the main pancreatic duct wall were significantly associated with the diagnosis [173]. However, these results should be confirmed in prospective studies. Finally, data were presented from an ongoing prospective, randomized non-inferiority study in patients with acute upper abdominal pain [174]. The study evaluated the strategy of performing a primary endoscopic and ultrasonic diagnostic by EUS compared with the conventional diagnostic algorithm of transabdominal ultrasound followed by EGD and eventually followed by EUS. To date, 125 patients have been included and the results suggest that single diagnostic EUS provides a significantly higher diagnostic yield than the combination of transabdominal ultrasound and EGD (65.6 % vs. 53.6 %), failing in only two cases (miss rate 1.6 %).

Natural orifice transluminal endoscopic surgery

Last year’s meeting showed a trend towards a decline in the number of presentations on NOTES [17], and this trend continued at UEGW 2011. This is to be expected as there is usually a decrease in initial enthusiasm following the introduction of a new technique and, to some extent, this could denote that some aspects of the technique are becoming integrated into clinical practice [175] [176]. However, another explanation for the reduced interest in NOTES at gastroenterology meetings could be a gradual shift of the technique from the gastroenterologist to the surgeon, as surgeons are increasingly engaged in performing these procedures [177]. Although much has been done to date, NOTES remains in the experimental phase and there is still room for related research in the future [178]. Lately, NOTES has been applied in humans [179], but currently remains controversial and has not yet displayed the results expected. Various issues including indications, access, closure, orientation, and safety remain open [177] [180] [181] [182] [183].

UEGW 2011 featured a few studies on NOTES applications mostly on the classical topics of pancreatic necrosectomy and closure techniques. Patients with signs of infected necrotizing pancreatitis need to undergo necrosectomy. Pancreatic necrosectomy is therefore one of the most “established” applications of NOTES in humans [184]. An interesting multicenter randomized trial from The Netherlands, comparing endoscopic necrosectomy with its surgical counterpart was presented at UEGW [185]. A total of 20 patients with signs of infected necrotizing pancreatitis were randomized to undergo endoscopic necrosectomy (performed following transgastric puncture and balloon dilation) or surgical necrosectomy (consisting of video-assisted retroperitoneal debridement or laparotomy), using serum interleukine-6 (IL-6) levels as the primary endpoint. Secondary clinical endpoints included a composite of death or major morbidity (new-onset multiple organ failure, intra-abdominal bleeding, enterocutaneous fistula) and other morbidity (pancreatic fistula, new onset diabetes or use of pancreatic enzymes). Endoscopic necrosectomy reduced the proinflammatory response (reflected by reduced IL-6 levels) as well as the composite endpoint of death and major morbidity compared with surgical necrosectomy (1 /10 vs. 6 /10 patients, respectively).

The management of iatrogenic perforations of the gastrointestinal tract is a basic aspect that influences safety and outcomes not only in NOTES but also endoscopic resection. Although surgical repair was previously considered the standard treatment for perforations, endoscopic closure has recently advanced and is nowadays increasingly attempted, as secure endoluminal closure of perforations obviates the need for surgery. An interesting series from Belgium of 40 234 procedures (including EUS, ERCP, and EMR/ESD) with 44 perforations displayed improved outcomes in terms of length of hospital stay for the endoscopic closure techniques compared with surgery for upper gastrointestinal perforations [186].

The recently developed OTSC was presented in some interesting studies at UEGW 2011. In an experimental animal study from Germany, a prototype OTSC device, which consists of a large transparent plastic cap loaded onto the tip of the endoscope, was used for the development of a novel endoscopic full-thickness resection technique with closure of the colonic wall in a single procedure [187]. In eight female domestic pigs under general anesthesia, 2-cm large lesions were created endoscopically by APC markings in the distal colon. The colonic wall was then pulled and sucked into the cap, preloaded with an electric snare and a special 14-mm OTSC. Full resection was successful in all eight animals. In one case two additional clips had to be placed for complete closure and in one case clip release failed. Another animal study concerning the OTSC presented data from a porcine survival model where feasibility and safety of gastric and colonic NOTES closure using the OTSC system were compared (10 animals in each group) [188]. Closure was successful in all 20 animals (mean application time was 8 and 5 minutes, respectively). Histology revealed transmural healing in all animals, but signs of microscopic inflammation in 9 /20 animals warrants further investigation. Moreover, endoscopic “full-thickness” resection of subepithelial gastric masses is often associated with inadequate closure of gastric perforations. Use of the OTSC could provide secure closure in these cases.

An interesting German prospective study reported data on endoscopic snare-resection of gastric subepithelial masses ( < 3 cm) in 16 patients [189]. Although endoscopic resection was possible in 12 /16 cases, perforation occurred in four patients, which was successfully treated with an OTSC clip. The technique per se can be regarded as a step towards transgastric endoscopic surgery, and the possibility of secure closure with the OTSC has a pivotal role providing safety of the procedure. Such tools, together with other appropriate accessories might help to improve NOTES, so that the procedure can find an appropriate place in endotherapy.

Percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG) placement has become routine practice for most endoscopy units [190] [191]. In cases of PEG placement for esophageal cancer or malignancies of the throat, the tumor may come into direct contact with the placement tube or the security plate during the procedure. Development of metastases at PEG outlet sites has been reported in single cases, but are generally regarded as a rare complication [192]; as many of the patients might not live long enough to reach a late stage, the true seeding rate in unknown. This was prospectively evaluated in an interesting pilot study presented at UEGW 2011. Data were presented from 15 consecutive patients (13 with throat tumors and 2 with esophageal cancers) of 50 intended patients with tumors that allow direct contact with the placement tube during insertion. Directly after PEG placement (standard pull-technique), brush cytology was acquired from the PEG tubing as well as from the transcutaneous incision site; the rate of malignant seeding was 27 %. As oncological treatments become more effective these results should possibly alert us to the possibility that malignant seeding is not as rare as previously considered. However, as the patient sample is small, results should first be confirmed before they can be extrapolated and replacement of the pull-technique with direct placement procedures is suggested.

Competing interests: None.

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Corresponding author

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