Highlights of United European Gastroenterology Week 2006

• Sophisticated imaging of the upper gastrointestinal tract
• Will endoscopic submucosal dissection ever be exported from Japan?
• Interventional endoscopic methods for Barrett’s esophagus
• Colonic imaging, colonic screening - what is best?
• Around colonoscopy
• Gastrointestinal tract palliation
• Bleeding studies
• Capsule and double-balloon endoscopy - a lessening of interest?
• Endoscopic ultrasonography (EUS) and tissue diagnosis
• Pancreatobiliary EUS - a reliable replacement for MRCP or diagnostic ERCP?
• ERCP news
• Randomized studies
• Nonrandomized series
• Innovations and miscellaneous
• References

The United European Gastroenterology Week (UEGW) of 2006 offered an interesting variety of topics, and included many randomized studies that had not been previously presented at major meetings. Papers presented at plenary sessions will be given some priority in the following paper, whereas the selection of topics from abstracts, on the basis of poster presentations, has been more limited, necessarily reflecting to some extent the personal taste of the reviewer.

Sophisticated imaging of the upper gastrointestinal tract

Narrow band imaging (NBI) is among the most widely available of advanced imaging techniques, so the appearance of multiple studies on this topic is not suprising.

Previous studies, especially by the Amsterdam group [1], have shown some value in surveillance of Barrett esophagus. In a comparative study on 36 patients who had undergone two procedures (obviously all had conventional endoscopy with methylene blue staining first, and the second endoscopy with NBI imaging within 12 weeks; blinding was not commented upon), the identification rates for high-grade intraepithelial neoplasia (HGIN) were 8.3 % vs. 11.1 %, respectively [2].

The Amsterdam group also showed an added value when imaging was supplemented by autofluorescence endoscopy (”triple imaging”) [3]. This approach which consists of lesion detection by conventional or autofluorescence endoscopy and further characterization of lesions found by NBI was tested in a multicenter setting in 31 cases. Overall, 12 patients had neoplasia (HGIN or more); seven were diagnosed by conventional imaging; three by autofluoresence endoscopy only; and two by random biopsies only. The high rate of false-positive autofluorescence lesions (86 %) was substantially reduced by NBI (to 19 %) [4].

Another study correlated NBI patterns with the histology of Barrett’s esophagus epithelium and Barrett-associated neoplasia [5].

Optical coherence tomography (OCT) has been around for quite some time and data on its application in Barrett’s esophagus have been published [6]. A study from Russia focused on the correlation between OCT images and bioptic histology (the method of precise matching was not reported), and found sensitivity and specificity rates for neoplasia of 78 % and 85 %, respectively [7].

Confocal laser microscopy (CLM) has attracted much attention, and superb results for the colon, stomach and esophagus, with various methodological approaches, have been published [8] [9] [10]. Additional uses for the endoscope with an inbuilt CLM function (manufactured by Pentax) are reported for niche indications, such as in a case of gastric amyloidosis [11]. An alternative for easier CLM application may be the use of a probe (MaunaKea, Paris, France), which was tested in 10 patients with various indications [12].

Will endoscopic submucosal dissection ever be exported from Japan?

Endoscopic submucosal dissection (ESD) is a new resection technique developed in Japan that aims at en bloc resection of superficial gastrointestinal lesions; first reports were disappointing with most rates for complete resection being below 80 % [13] [14]. However, as evidenced in a recent issue of this journal [15] [16] [17] as well as in other publications [18], current rates for success - defined as achieving a complete resection within one piece - have mostly been above 90 %, although at the cost of somewhat higher complication rates and much longer procedure times.

Again from Japan, quite a number of ESD abstracts were presented at UEGW 2006, that are summarized in [Table 1] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29]. The results are impressive in terms of complete en bloc resection and complications, although the latter seem to be more frequent than with endoscopic mucosal resection (EMR). Notably, an abstract focusing on bleeding as a complication reported a much higher rate (7.6 %) than in the other abstracts referred to here [30]. Furthermore, in a broad application in a Japanese multicenter study, the success rate in terms of complete R0 resection was well below 80 % and not as good as in single series [26].

Other abstracts could not be included in [Table 1] since results for different locations were lumped together. In one such large study, a new flushing knife was used in 419 cases (33 esophagus, 283 stomach, 183 colorectum) with a ”dream“ rate of 99 % of resections being complete (en bloc and R0),with a median tumor size of 14 mm and only two pinhole perforations that were closed by clipping [31]. A newly developed spatula knife was tested in 70 gastric and 15 colonic lesions, similarly having a 100 % success rate and with only three perforations that were also closed by clipping [32]. An interesting method using a combination of balloon entrapped between mucosa and muscularis and a knife for cutting was tested successfully in pigs [33]. New devices for submucosal injection using a waterjet system and combination of jet and dissection knife were tested in patients [34] and in pigs (a combined knife) [35]; both devices look promising. An alternative to single-scope methods was presented in which endoscopists used two scopes (thin and conventional) introduced through a large overtube. A small pilot series included 10 patients with early gastric cancer; they were successfully treated within a mean procedure time of 58 min [36]. Alternatively, an external grasping forceps could be used in distal gastric cancers, as reported for 46 cases.

There was no difference in effectiveness and complications between patients older or younger than 75 years with esophagogastric ESD (n = 221) [37]. Surprisingly, there was no difference in efficacy and complications between experienced ESD endoscopists (233 lesions) and trainees (62 lesions) [38]; this was confirmed by another abstract, also from Japan [39]. However, first European results, still on an early part of the learning curve, showed much higher complication rates with gastric ESD [40].

Other studies demonstrated the use of ESD in special situations such as neoplasia recurrence in the colon; here it was superior to EMR in achieving complete resection (56 % vs. 34 %) despite ESD providing larger samples (25 vs. 8 mm) [41].

Is EMR on its way out in Japan? A retrospective series from 11 centers looked at 411 EMR and 303 ESD treatments of early gastric cancer, and found a much higher rate of en bloc resection (93 % vs. 56 %) with a still significant but less dramatic difference in complete (R0) resection rates (74 % vs. 61 %), at the cost of higher complications (3.6 % vs. 1.2 %), all managed conservatively. The 3-year cumulative disease-free survival rate was also higher with ESD (98 % vs. 92.5 %), but not the overall survival (98.5 % vs. 99.7 %) [26]. The results show a better technical and tumor efficacy but no overall benefit in terms of patient survival. This makes ESD superior but not mandatory. In addition, European series on esophagogastric EMR have been reported, with similar [42] [43] or somewhat inferior success rates [44]

Interventional endoscopic methods for Barrett’s esophagus

In patients with Barrett’s esophagus, the switch from surveillance to interventions, such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), is usually considered to be indicated if lesions with high grade intraepithelial neoplasia (HGIN) or mucosal cancer have been diagnosed and confirmed. It has recently been shown that the risk of neoplasia development may have been overestimated due to publication [45] and other biases. In a hospital-based prospective surveillance program including 98 Barrett’s esophagus patients (mean of 3.9 follow-up endoscopies), one case of advanced neoplasia (HGIN and cancer) was found, diagnosed 2 years after the index endoscopy. Otherwise 18 low grade intraepithelial neoplasias were diagnosed, 8 at the index endoscopy and 10 during follow-up, with this diagnosis being maintained in only 4 of them. There was also some endoscopic regression of Barrett’s esophagus length in 25 % of cases [46]. In an Italian prospective study, 135 of the 181 included patients without neoplasia at index endoscopy completed a 5-year follow-up; eight developed HGIN, but the time points were not recorded. Low grade intraepithelial neoplasia (LGIN) was found in 11 cases [47].

In the case of neoplasia (HGIN or more), different endotherapy concepts persist, regarding methods (resection vs. thermal ablation), and whether the lesion only should be removed, if it is identifiable, with the remaining Barrett’s esophagus left and kept under surveillance, or whether complete ablation/resection of Barrett epithelium should be aimed at. The latter much more radical approach is increasingly favored, and in an update of previous publications [48] [49], a group from Marseille presented their long-term results on 41 patients with HGIN or early cancer and two-stage circumferential EMR, with a mean follow-up of 32 months; complete disappearance of Barrett’s esophagus epithelium was recorded in 76 %, and 12 % had recurrent neoplasia. Eight cases of bleeding and two perforations occurred during resection, and in the long term, only one stricture developed [50]. Another abstract from Amsterdam, also updating a recently published series [51], reported on 58 patients with a median Barrett’s esophagus length of 4 cm. In 56 patients (with treatment in two cases discontinued due to comorbidity), who underwent several sessions to eradicate the entire Barrett’s esophagus by piecemeal EMR, sometimes supplemented by argon beamer ablation, complete eradication of neoplasia and Barrett’s esophagus epithelium were achieved in 100 % and 93 %, respectively (follow-up 13 months). Acute complications occurred in 3 % and late strictures in 38 % [52].

Thermal ablation using circumferential radiofrequency application via balloons (the BARRX system), applying short bursts of high energy (300 W) to destroy 0.5 mm of tissue, was tested in a pilot trial in a small inhomogeneous group of 11 cases, still harboring LGIN or HGIN, with six having had prior EMR for early cancer or HGIN. The Barrett’s esophagus length was 3-7 cm. The intraepithelial neoplasia was destroyed in 10 of 11 cases, and the Barrett’s esophagus area was reduced by 99 % at 4 months - superb results [53].

Two interesting case reports from Amsterdam dealt with a combination of EMR and BARRX treatment. In one patient with early cancer in a 5-cm Barrett length, there was complete ablation of the lesion and Barrett’s esophagus [54]. Another patient had circumferential resection of Barrett’s esophagus including HGIN and then had stent insertion to prevent strictures. However, a second stent became necessary due to stricture recurrence after removal of the first one, and this second stent was difficult to remove. The stricture recurred and required endoscopic dilations [55]. Whether this stent technique should be introduced remains questionable.

Colonic imaging, colonic screening - what is best?

Driven by the experience, in a few countries, of screening colonoscopy and alternative methods in the attempt to identify colorectal cancer (CRC), there was a strong focus on colonic imaging at UEGW 2006. Screening colonoscopy itself was the topic of some selected abstracts. A prospective comparison of 5070 screening and 8161 diagnostic colonoscopies in one German gastrointestinal practice during a 4-year period revealed similar CRC rates (0.9 % vs. 1.2 %); 93 % of cancers were of stages UICC I-II, contrasting with 63 % in diagnostic cases. Adenoma rates were not compared in this abstract [56].

An interesting randomized study is ongoing in Portugal, where people willing to undergo CRC screening have been randomly allocated to either yearly fecal occult blood testing (FOBT) or to flexible sigmoidoscopy every 5 years. Colonoscopy is performed with any positive FOBT or if risk lesions are evident on flexible sigmoidoscopy. Among the 4757 persons enrolled, compliance with the first FOBT was higher than with flexible sigmoidoscopy (91 % vs. 84 %), with the colonoscopy rate also being higher in the FOBT group (31 % vs. 8 %). The rates of detected cancers and risk adenomas were 0.5 % and 3.6 % in the FOBT groups and 0.5 and 3.7 % in the sigmoidoscopy group [57]. Further study progress will show the final outcome, likely to be higher rates, after repeated FOBT, and - although much later - the final effect of both strategies on CRC incidence and prognosis.

Among the techniques providing better contrast, narrow-band imaging (NBI) was tested with regard to adenoma detection rate; in an interim analysis of an ongoing prospective randomized trial, there seemed to be an advantage, at the cost of an increased identification rate for hyperplastic polyps also [58]. Another randomized study reported results for 52 enrolled patients who were having cancer or polyp follow-up; a higher number of polyps were detected in the NBI group (91 NBI vs. 44 controls; P = 0.03) and also, but not significantly, adenomas (42 NBI vs. 26 in the conventional group) [59]. In another small single-arm study using tandem methodology (first conventional then NBI colonoscopy), 48 patients were included and NBI found more lesions (134 vs. 116), but no precise histological details were given [60].

Do simple technical modifications of colonoscopes and colonoscopy help? A randomized study investigated position changes and looked specifically at three colonic segments, with randomization either to left lateral position throughout or to position changes, with total examination time fixed to 6 min for each position sequence. Polyp detection increased by 39 % with position changes (25 vs. 18 polyps, 13 vs 11 adenomas), and the study is ongoing [61].

Whether virtual colonography will ever become a serious competitor in colon screening may depend on the method used (computed tomography [CT] with its associated radiation exposure, or magnetic resonance imaging [MRI]), and the continued necessity for bowel preparation. Preparation-less colonoscopy has repeatedly been advocated, mainly with MRI, but has obviously not gained widespread acceptance. In a large screening study involving 414 asymptomatic individuals, with an average age of 63 years, the preparation regimen consisted of 2 l of prep solution (consisting of 5 % gastrografin, 1 % barium and 0.2 % locust bean gum) with every meal for 2 days (!). MR colonography was then performed, with a rectal enema using 2.5 l of warm water. Colorectal adenomas >5 mm in size were detected by colonoscopy in 8 %, and an MRI sensitivity and specificity of 80 % and 93 % were achieved. On a scale of 1 (excellent) to 10 (poor), MRI colonography was rated with a mean value of 3.4 (colonoscopy rating 3.0) [62]. Leaving aside any question of whether the accuracy values are sufficient, can a regimen that requires patients to drink 12 l of a solution over 2 days and then to have an enema, in any way resemble a prepless procedure?

In an entirely different approach, virtual colonography, this time based on CT, was assessed for preoperative staging of already detected CRCs. Using 270 CRC cases as a basis, sophisticated criteria were developed for colorectal wall imaging, and these were tested, perhaps on the same patient collection (the study had two phases but it does not become clear in which respect these were different). Despite the methodological biases, the parameters developed led to a staging correlation of 60 %-70 % for earlier stages (T1-2) and 83 % for more advanced stages (T3-4) [63].

Around colonoscopy

Colonic preparation using lavage solution is still regarded as quite unpleasant by patients and may be one of the major obstacles to achieving higher compliance with colonoscopy, especially in the screening setting.

A multicenter German study apparently using a 2 : 1 randomization on 356 diagnostic and screening cases compared 2 l polyethylene glycol solution plus ascorbic acid (MoviPrep) with sodium phosphate (Fleet Phospho-soda). Bowel cleanliness was assessed blindly on the basis of videotapes and graded 0 - 4, where complete visualization was assumed if grades 2 - 4 were reached. Although this is not specified in the abstract, assuming 0 as very poor and 4 as excellent, 2 and 3 must mean moderate and good visibility, so the inclusion of moderate results into the category of complete visualization may appear problematic; and also the times to achieve complete cleanliness by rinsing are not given. In any case, a 2 - 4 rating for all segments was reached in 93 % of individuals with the new preparation, compared with only 28 % with the sodium phosphate preparation [64]. This is equivalent to or even better for the MoviPrep test group than colonic lavage using 4 - 6 l as reported in the literature, and also much worse for sodium phosphate in the control group when compared with other recent studies [65] [66] [67]. Whether the conclusion should already be that MoviPrep ”is an ideal bowel preparation for colon cancer screening” remains to be seen.

Another randomized study compared three regimens of polyethylene glycol bowel preparation in 350 patients, using 3 l or 4 l of conventional solution or 4 l of polyethylene glycol with electrolytes. It was found that volume mattered (4 l compared with 3 l had an efficacy of around 90 % vs. 72 %) but not the addition of electrolytes (89 % vs. 90 %) [68].

Gastrointestinal tract palliation

Esophageal stenting is the method of choice for palliation of malignant dysphagia; whether adding antireflux valves to the stents offers any benefit over open stents has never been shown. In a randomized study comparing both models of the so-called Choo stents (fully covered), results (which may have been intermediate) on 38 cases were reported; there was efficacy concerning dysphagia, less radiological reflux, and less clinical regurgitation (on a score 0 - 16, 1.4 vs. 6.5; P < 0.05), but at the cost of a higher migration rate (4 vs. 1; not significant) [69].

In the colon, stents are used both for palliation and in (sub)acute tumor obstruction as a ”bridge to surgery.” The latter indication, i. e. emergency placement in acute left colonic obstruction, was prospectively studied in a multicenter setting in France. The occlusion was successfully bridged in 95 % of 45 patients treated, and elective surgery was performed in 22 of the patients (with two having additional radiotherapy), whereas stenting remained a palliative option in 20 cases; the remaining patient died 4 days after insertion. Three severe complications occurred [70].

Bleeding studies

The interest in bleeding continues at a moderate level. The following discussion focuses only on randomized studies. In an interesting randomized trial, scheduled repeat endoscopy and re-treatment was compared with high dose intravenous omeprazole infusion, in the case of persistent stigmata in 386 patients with successful endotherapy of Forrest I - IIb ulcers. The regimens were equally effective in terms of recurrent resp. sustained bleeding (8.7 % vs. 8.2 %). It is not said however, whether the repeat endoscopy group remained entirely without acid suppression, which appears to be unlikely [71].

The effect of a second-look endoscopy, recently supported by positive findings in a Hong Kong study [72], was again assessed in a prospective randomized trial including 146 cases of Forrest I-IIb ulcer bleeders; the reduction in rebleeding (10 % vs. 16 %) was not significant [73], but perhaps the study was underpowered.

Finally, in patients with suspected ulcer bleeding (no cirrhosis present or known), a randomized multicenter study compared intravenous infusion of somatostatin 12 mg/d with placebo. End points were active bleeding or the need for therapeutic intervention, including endoscopy, within 72 h (endoscopy for primarily diagnostic reasons had to be performed within 8 h). This study recruited 445 patients, and the diagnosis of peptic ulcer bleeding was correct in 83 %. Overall there was no difference in failure rate (34 % vs. 36 %); a difference was only evident when stigmata for Forrest I - IIb were present (36 % vs. 48 %; P = 0.034) [74]. It is difficult to draw conclusions since the presence of stigmata is not primarily known in these cases.

The use of Histoacryl in esophagogastric varices is based on very few randomized trials [75] [76] [77]. A prospective randomized study compared Histoacryl injection to ligation in 37 cases, with no appreciable differences in effectiveness of eradication (Histoacryl 77 %, and ligation 85 %; perhaps the study was underpowered), but with an increased complication rate in the Histoacryl group (major complications in 29 % vs. 10 %). [78]. This puts Histoacryl injection back into a role as a salvage therapy for esophageal varices, which is how most endoscopists regard and use it anyway.

Capsule and double-balloon endoscopy - a lessening of interest?

No major breakthrough studies on either topic were reported. A mixed indication series from China was presented that included 147 patients who underwent double-balloon enteroscopy (DBE) (84 with bleeding as indication). Both routes were explored in only 43 cases; nevertheless an 98 % performance success rate was reported. Possible reasons were found in 75 % of those with bleeding, and in some 50 % - 60 % of those with other indications such as pain, diarrhea, vomiting and so on, in obviously very well selected cases [79]. In a Korean multicenter study on 311 DBE procedures in 255 patients, the main indication was bleeding (in 62 %) and the yield for this indication was 74 %; for the indication of chronic pain (15 % of patients) the yield was 75 % [80]. In a small series of 14 gastric lymphoma patients, DBE found intestinal lesions in five, of various histological types that were not detailed in the abstract [81]. In another series, 16 patients with Peutz-Jeghers’ syndrome underwent 37 procedures which led to the removal of 34 polyps, with two post-procedure bleedings [82].

The relative values of DBE and capsule endoscopy are still ill-defined. A prospective comparative study between both techniques in 24 patients (out of 86 eligible cases) involved a variety of indications, so meaningful comparative data were limited [83]. In another study [84], following positive results on capsule endoscopy for obscure bleeding, 67 patients underwent 77 DBE procedures, with a diagnostic yield of 57 % (as compared to 41 % with push enteroscopy). The yield was to some extent dependent on the nature of the lesions, as rated, using a scale developed by French endoscopists, according to the likelihood that the lesion found might be responsible for the bleeding [85]: High probability lesions (called ”P2”) had a 74 % yield, whereas those with low probability had a much lower yield (31 %). The study is noteworthy in that capsule endoscopy findings led to DBE findings in only slightly more than half of the cases; perhaps stratification according to the system described above would help. Outcome data were not reported.

Finally, a study based on a large registry of 3031 capsule endoscopy examinations focused on 74 tumors (2.4 %), mostly found at capsule endoscopies performed for bleeding indications (90.5 %) [86]. Another study concerned the use of capsule endoscopy in refractory celiac disease, reporting a much higher yield of ulcerations in type II than in type I disease (4/5 vs. 1/10) [87].

Endoscopic ultrasonography (EUS) and tissue diagnosis

Newer needles, designed to provide larger specimens or offering other advantages, have been presented. The Trucut needle, previously shown to offer limited benefit [88] [89] [90], was tested and compared with conventional 22-G needles in only 10 patients with submucosal lesions. Although the Trucut needle was inferior in terms of final diagnostic yield (70 % vs. 90 %), determination of c-kit to diagnose gastrointestinal stromal tumors (GISTs) was possible in all six cases in whom it was indicated [91]. In a larger study on submucosal tumors a 19-G prototype needle was used, with a mean number of 4 passes; a tissue yield of only 74 % was achieved, and this only with repeated procedures in two cases. It must also be mentioned that major complications were encountered in 9 % (1 sepsis and 1 abscess) [92].

That imaging might replace tissue diagnosis is a long-held dream in the field of ultrasound and endoscopy. Elastography has recently been reported, with moderate results [93], and the same group, now supported by a multicenter setting, assessed 101 cases of lymph nodes and 121 of pancreatic masses, all obviously with tissue confirmation by EUS fine-needle aspiration (EUS-FNA), which is a moderately suitable reference standard. Sensitivity and specificity values were 88 % and 88 % for lymph nodes, and 81 % and 92 % for pancreatic masses [94], but the pre-test likelihoods according to clinical or imaging data, and the blinding of the assessment are not known. Another group examined 78 lymph nodes by EUS elastography, using EUS-FNA, surgery or follow-up as reference standard; sensitivity and specificity were 83 % and 89 %, respectively [95].

Pancreatobiliary EUS - a reliable replacement for MRCP or diagnostic ERCP?

Studies continue to focus on the diagnosis of common bile duct (CBD) stones, consistently showing high accuracy rates for endoscopic ultrasound (EUS) in this respect. A plenary session presentation from Spain described the prospective examination with EUS of 21 patients with biliary colic or recurrent pancreatitis and with two previous transabdominal ultrasound examinations with normal findings. EUS was used for diagnosis of cholelithiasis including sludge in both CBD and gallbladder, with the gold standard of ceruletide-induced bile aspiration and analysis. Unfortunately, 100 % of patients had microlithiasis on the aspiration test, and EUS recognized all but one; however due to the absence of specificity data, this study does not allow for assessment of clinical value [96].

A negative EUS excluding a suspected pancreatic cancer is thought to be reliable, and a retrospective series on 412 cases without mass lesion or negative on FNA showed a negative predictive value of 95.4 %. Two patients in the group of 253 without visible lesions (both from the group of patients in whom diffuse chronic pancreatitis was diagnosed) were found to have cancers, and 17 cancers were found in the group of 159 with mass lesions negative on FNA [97]. The latter certainly represents a set of cases in whom a negative FNA should be looked at and in whom other parameters should also be taken into account.

EUS-guided FNA is mostly used - besides for mediastinal tumors and lymph nodes - for tissue diagnosis of pancreatic masses. Pancreatitis is a feared complication of pancreatic EUS-FNA, but the incidence is obviously low [98]. This was confirmed by a prospective study including 100 patients who underwent pancreatic FNA among whom rates were found of 12 % for hyperamylasemia and 2 % for clinical pancreatitis [99].

That EUS can also replace therapeutic endoscopic retrograde cholangiopancreatography (ERCP) as salvage treatment was shown in a fairly large series of 33 patients in whom EUS-guided access was attempted (29 bile duct, 4 pancreatic duct). A stent was placed in 22 of the 30 procedures that were finally attempted (no needle access was possible in 3), at the cost of a 31 % rate of complications; these were mostly mild, but severe complications and one death did occur [100].

ERCP news

Randomized studies

Patient positioning. Endoscopic retrograde cholangiopancreatography (ERCP) with the patient in a supine position has recently been shown in a randomized study to be inferior to performance using the prone position, in terms of efficacy (CBD cannulation) and safety (aspiration, etc.) [101]. The authors of this study conceded that results may be different in expert centers where clinicians are used to supine ERCP positioning, and this was shown in a randomized study from Rome including 100 cases; equal cannulation rates and equal safety were found, but the study was powered mainly for the aim of examining cannulation efficacy [102].

Cannulation with the primary use of a guide wire may be better and be safer. In a randomized study involving 430 patients without periampullary tumors, cannulation efficacy was indeed higher when a guide wire was used (85 % vs. 74 %), with secondary success also being achieved in more cases with the alternative method (48 % vs. 31 %). Pancreatitis however was not significantly different between the two groups (total rate 6.4 %) [103].

Prevention of pancreatitis by medication has been tested in numerous previous trials, mostly unsuccessfully. This was confirmed by a French study involving 208 patients, in which intravenous nitroglycerine was tested (10 pancreatitis cases in the nitroglycerine arm vs. 15 in the placebo arm) [104]. In previous studies, only diclofenac, a nonsteroidal anti-inflammatory drug (NSAID), has been shown to reduce post-ERCP pancreatitis, in one trial [105], which however has never been replicated. In a randomized study from Tehran, of 490 ERCP patients (it was not reported whether all had an intact papilla), a suppository of 100 mg was now tested; a lower pancreatitis incidence was found in the indomethacin group (7 cases vs. 15 cases in the placebo group) which, however, was not statistically significant. Pancreatitis was mild in all seven cases in the indomethacin group, whereas it was moderate to severe in a third of the cases in the control group (significance not reported). Thus, the study leaves the question open, but may have been underpowered [106].

Pancreatic stenting is the other measure which has been shown to prevent post-ERCP pancreatitis, at least in risk cases and much more consistently (according to meta-analysis) is. This was again confirmed by a randomized study on 201 patients from Japan: The pancreatitis rates were 3.2 % in the stent group vs. 13.6 % in the control group [107].

Nonrandomized series

Balloon dilation of the papilla was introduced and evaluated some years ago but has not really been incorporated into clinical management, perhaps partly due to some evidence of severe complications [108], although this has not been confirmed by other studies [109] [110]. Nevertheless, studies from the Far East continue to focus on this topic. An obviously retrospective series from Taiwan included 405 patients with CBD stones who were treated using a larger balloon (0.8-2.0 cm) adapted to the CBD diameter. Among the acute complications, there were rates of 2 % for bleeding and 0.5 % for pancreatitis (it is perhaps a little hard to believe that this could be reproduced in other centers). Long-term follow-up, performed in only 264 cases, showed a rate of 6 % for stone recurrence [111].

Cannulation failure can be tackled with one of several options, and in a retrospective nonrandomized analysis, needle-knife cutting had the same success as persistence but had lower pancreatitis rates [112]; however, conclusions from nonrandomized studies are quite limited. An alternative pre-cutting technique may be to perform a pancreatic sphincterotomy in the direction of the bile duct, using conventional sphincterotomes, once the pancreatic duct has been cannulated. This approach is avoided by most ERCP practitioners, but has been shown in uncontrolled series to be quite effective and safe [113] [114] [115]. This was confirmed in a small series of 29 such cases, but compared with 18 cases where the needle-knife was used, 1 severe pancreatitis occurred in each group [116].

Postoperative anatomy and ERCP, either using conventional ERCP scopes or the double-balloon enteroscope, was the subject of some abstracts. Using conventional scopes in 43 pancreatoduodenectomy patients (a duodenoscope in 57/65 procedures), a 77 % success rate for reaching either the biliary or pancreatic duct was reported [117]. In 11 patients with a Roux-en-Y anastomosis, the double-balloon enteroscope was used. All anastomoses could be reached and cannulation succeeded in eight [118]. Another study from Japan included 16 patients with Roux-en-Y anastomosis; there was therapeutic success in 12 [119]

Ampullectomy for adenomas of the papilla is still not standardized, in terms of current and post-resection pancreatic duct stenting. In a prospective multicenter study, 86 adenoma patients were assessed, but EST and/or stenting was unfortunately dealt with as a separate issue. Overall, a 30 % complication rate (22 % pancreatitis, 1/19 severe) was encountered, and pancreatitis seemed to be more frequent in nonstented cases [120].

Innovations and miscellaneous

Endoscopic vertical gastroplasty can be done using a new device, that achieves gastric volume restriction by means of two disposable staplers released sequentially to create a sleeve/pouch based on the lesser curve. In a pilot series of 21 cases there were mild to moderate adverse events, consisting of nausea, vomiting, pain, or dysphagia. At 1 month, the median weight loss was 16 pounds (range 9-28) [121]

A new autofluorescence endoscope manufactured by Pentax was presented; in a patient group of 27 with early gastric cancer, with purely descriptive data reported, the delineation of tumor extent corresponded with that found by pathology [122].

Percutaneous endoscopic gastrostomy (PEG) placement has become much easier with the advent of a new system (Pexact) with a temporary fixation plate, only requiring a small scope for observation and obviating the need for transoral pull-through of the PEG plate. This gastropexy principle was evaluated for PEG placement with or without antibiotics in a randomized trial involving 63 patients, and no difference was found [123]. Whether this might translate into a guideline change, abolishing the need for prophylactic antibiotics remains to be seen.

Celiac disease prevalence in unselected dyspepsia patients, has never been studied systematically in a large cohort and data may have been flawed by various selection biases. A hospital-based prospective study in 626 dyspepsia patients (Rome II criteria) showed endoscopic evidence in 0.5 % and histologic evidence (routine biopsies) in 1.9 % (only Marsh III and IV), i. e. only by histology in 7/12 such cases. Prevalence was 0 in ulcer-like dyspepsia, and otherwise higher in dysmotility-like dyspepsia than in indeterminate dyspepsia [124].

Competing interests: None

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T. Rösch, MD 

Central Interdisciplinary Endoscopy Unit

Department of Gastroenterology, Hepatology and Metabolic Diseases

Charité University Hospitals, Campus Virchow Hospital

Augustenburger Platz 1

13353 Berlin

Fax: +49-30-450553902

Email: Thomas.Roesch@charite.de

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T. Rösch, MD 

Central Interdisciplinary Endoscopy Unit

Department of Gastroenterology, Hepatology and Metabolic Diseases

Charité University Hospitals, Campus Virchow Hospital

Augustenburger Platz 1

13353 Berlin

Fax: +49-30-450553902

Email: Thomas.Roesch@charite.de