Michael Bourke - Academia.edu (original) (raw)
Papers by Michael Bourke
Endoscopy International Open, 2019
Background and study aims Colonic angioectasia are the most common vascular lesions in the gastro... more Background and study aims Colonic angioectasia are the most common vascular lesions in the gastrointestinal tract and are among the most common causes for chronic or recurrent lower gastrointestinal bleeding. Endoscopic treatment involves a variety of techniques, all of which focus on destruction of the mucosal abnormality. However, recurrent bleeding after endoscopic treatment is common, with more than one treatment frequently necessary. We report a technique for definitive treatment of colonic angioectasia by targeting the feeding submucosal vessel. Patients and methods Analogous to endoscopic mucosal resection, a submucosal injection is made beneath the target lesion which is then removed by electrocautery snare resection of the mucosal lesion. The exposed feeding vessel is then destroyed by application of coagulation current. The resection defect is closed by clips. Results Six patients with a total of 14 colonic angioectasia were treated over the study period. All lesions were ...
Modern Pathology, 2020
Endoscopic resection (ER) allows optimal staging with potential cure of early-stage luminal malig... more Endoscopic resection (ER) allows optimal staging with potential cure of early-stage luminal malignancies while maintaining organ preservation. ER and surgery are non-competing but complementary therapeutic options. In addition, histological examination of ER specimens can either confirm or refine the pre-procedure diagnosis. ER is used for the treatment of Barrett's related early carcinomas and dysplasias, early-esophageal squamous cell carcinomas and dysplasias, early gastric carcinomas and dysplasia, as well as low-risk submucosal invasive carcinomas (LR-SMIC) and, large laterally spreading adenomas of the colon. For invasive lesions, histological risk factors predict risk of lymph node metastasis and residual disease at the ER site. Important pathological risk factors predictive of lymph node metastasis are depth of tumor invasion, poor differentiation, and lymphovascular invasion. Complete resection with negative margins is critical to avoid local recurrences. For non-invasive lesions, complete resection is curative. Therefore, a systematic approach for handling and assessing ER specimens is recommended to evaluate all above key prognostic features appropriately. Correct handling starts with pinning the specimen before fixation, meticulous macroscopic assessment with orientation of appropriate margins, systematic sectioning, and microscopic assessment of the entire specimen. Microscopic examination should be thorough for accurate assessment of all pathological risk factors and margin assessment. Site-specific issues such as duplication of muscularis mucosa of the esophagus, challenges of assessing ampullectomy specimens and site-specific differences of staging of early carcinomas throughout the gastrointestinal tract (GI) tract should be given special consideration. Finally, a standard, comprehensive pathology report that allows optimal staging with potential cure of early-stage malignancies or better stratification and guidance for additional treatment should be provided.
Medical Journal of Australia, 2018
VideoGIE : an official video journal of the American Society for Gastrointestinal Endoscopy, 2018
Gut and liver, Jan 11, 2017
Serrated polyps are important contributors to the burden of colorectal cancers (CRC). These lesio... more Serrated polyps are important contributors to the burden of colorectal cancers (CRC). These lesions were once considered to have no malignant potential, but currently up to 30% of all CRC are recognized to arise from the serrated neoplasia pathway. The primary premalignant lesions are sessile serrated adenomas/polyps (SSA/Ps), although traditional serrated adenomas are relatively uncommon. Compared to conventional adenomas, SSA/Ps are morphologically subtle with indistinct borders, may be difficult to detect endoscopically, are more prevalent than previously thought, are associated with synchronous and metachronous advanced neoplasia, and have a higher risk of incomplete resection. Although many lesions remain "dormant," progressive disease is associated with the development of dysplasia and more rapid progression to CRC. As a result, SSA/Ps are strongly implicated in the development of interval cancers. These factors represent unique challenges that require a meticulous a...
Endoscopy International Open, 2016
United European Gastroenterology Journal, 2017
Background: Endoscopic therapy, including by radiofrequency ablation (RFA) or endoscopic mucosal ... more Background: Endoscopic therapy, including by radiofrequency ablation (RFA) or endoscopic mucosal resection (EMR), is first line treatment for Barrett's esophagus (BE) with high grade dysplasia (HGD) or intramucosal cancer (IMC) and may be appropriate for some patients with low grade dysplasia (LGD). Objective: To investigate the molecular effects of endotherapy. Methods: mRNA expression of 16 genes significantly associated with different BE stages was measured in paired pre-treatment BE tissues and post-treatment neo-squamous biopsies were obtained from 36 patients treated by RFA (19 patients, 3 IMC, 4 HGD, 12 LGD) or EMR (17 patients, 4 IMC, 13 HGD). EMR was performed prior to RFA in 8 patients. Normal squamous esophageal tissues were from 20 control individuals. Results: Endoscopic therapy resulted in significant change towards the normal squamous expression profile for all genes. The neo-squamous expression profile was significantly different to the normal control profile for 11 of 16 genes. Conclusion: Endotherapy results in marked changes in mRNA expression, with replacement of the disordered BE dysplasia or IMC profile with a more "normal" profile. The neo-squamous mucosa was significantly different to the normal control squamous mucosa for most genes. The significance of this finding is uncertain but it may support continued endoscopic surveillance after successful endotherapy.
Endoscopy, Jan 4, 2015
Background and aims: Complete endoscopic resection (CER) of short-segment Barrett's esophagus... more Background and aims: Complete endoscopic resection (CER) of short-segment Barrett's esophagus with high grade dysplasia (HGD) and early esophageal adenocarcinoma (EEA) is a precise staging tool and achieves durable disease control. The major drawback is development of post-endoscopic resection esophageal stricture (PERES). No effective therapy to prevent PERES has been described. Viscous budesonide slurry (VBS) may have a role in the prevention of PERES by suppressing the post-CER inflammatory process. The study aim was to evaluate the efficacy of VBS for the prevention of PERES. Methods: Prospective data were collected on patients referred for CER of HGD or EEA. After January 2012, patients routinely received VBS (two 0.5-mg/2-mL budesonide respules mixed with sucralose) twice daily for 6 weeks following each stage of the CER schedule. All patients received high dose proton pump inhibitor therapy for the duration of CER and the following 3 months. Patients had no other interven...
Clinical Gastroenterology and Hepatology, 2015
BACKGROUND & AIMS: Use of precut sphincterotomy during endoscopic retrograde cholangiopancreatogr... more BACKGROUND & AIMS: Use of precut sphincterotomy during endoscopic retrograde cholangiopancreatography (ERCP) can increase the odds for cannulation success but is associated with increased risk of post-ERCP pancreatitis. Earlier, rather than delayed, use of precut sphincterotomy for cases with difficult biliary access might reduce this risk. We performed a meta-analysis of randomized controlled trials to determine how early use of precut sphincterotomy affects the risk of pancreatitis and rate of cannulation success compared with persistent standard cannulation. METHODS: We searched MEDLINE, EMBASE, and the Cochrane central register of controlled trials, along with meeting abstracts, through August 2014 for randomized controlled trials in which early precut sphincterotomy was compared with persistent standard cannulation in adults with difficult biliary access. Outcomes considered included primary cannulation success, overall cannulation success, incidence of post-ERCP pancreatitis, and overall adverse event rate. Findings from a random-effects model were expressed as pooled risk ratios (RRs) with 95% confidence intervals (CIs). RESULTS: We analyzed data from 5 studies (523 participants). The incidence of post-ERCP pancreatitis and success of overall cannulation did not differ significantly between the early precut and persistent standard therapy groups. Early use of precut sphincterotomy was associated with increased odds for primary cannulation success (RR, 1.32; 95% CI, 1.04-1.68). In subgroup analysis of studies that involved only fully qualified biliary endoscopists (not fellows), we found a significant reduction in risk of pancreatitis among patients receiving early precut vs the standard technique (RR, 0.29; 95% CI, 0.10-0.86). CONCLUSION: Compared with standard therapy, early use of precut sphincterotomy did not increase the risk of post-ERCP pancreatitis in a meta-analysis. When the procedure is performed by qualified biliary endoscopists, early precut can reduce the risk of post-ERCP pancreatitis. Rates of primary cannulation increase with early precut. Further studies are needed to confirm these findings.
Gastroenterology & hepatology, 2011
G&H Is bleeding a common complication of endoscopic mucosal resection? MJB Significant post-endos... more G&H Is bleeding a common complication of endoscopic mucosal resection? MJB Significant post-endoscopic mucosal resection (EMR) bleeding (PEB) is defined as bleeding that requires medical attention (ie, presentation to the emergency room and/or hospital admission). PEB occurs in 5-7% of colonic EMR cases. The need for medical assessment usually leads to hospital admission and ancillary investigations, including repeat colonoscopy and, less frequently, blood transfusion. The risk of developing PEB diminishes the advantages of EMR as a safe, cost-effective, minimally invasive therapy for advanced mucosal neoplasia of the colon.
Gastrointestinal Endoscopy, 2009
A 32-year-old man developed right upper quadrant (RUQ) pain, fever, and jaundice 10 days after la... more A 32-year-old man developed right upper quadrant (RUQ) pain, fever, and jaundice 10 days after laparotomy and resection of a 3-cm jejunal GI stromal tumor (GIST). Abdominal US revealed a dilated common bile duct (CBD), with biliary sludge as the likely cause for cholangitis. ERCP showed a dilated CBD with irregular ridging or serration of the CBD wall (A). After sphincterotomy, purulent bile and thick sludge were cleared. A 10F plastic stent was placed to ensure continued adequate drainage. Follow-up ERCP at 6 weeks showed complete resolution of the previous cholangiographic abnormalities (B). A 65-year-old man with fever, jaundice, and RUQ pain, unresponsive to parenteral antibiotics, underwent an emergency ERCP. Cholangiography revealed dilatation and irregular ridging or serration of the CBD wall (C). After sphincterotomy, purulent bile as well as small CBD calculi were cleared from the duct. A double-pigtail 7F stent was inserted for biliary drainage. Repeat ERCP after 6 weeks revealed resolution of the documented bile-duct-wall abnormality; however, a previously unapparent distal CBD stricture was found, and, subsequently, the diagnosis of cholangiocarcinoma was made (D).
Gastrointestinal Endoscopy, 2011
possibility of interobserver variance in NBI classification for colorectal lesions. Interpretatio... more possibility of interobserver variance in NBI classification for colorectal lesions. Interpretation of the magnifying NBI findings based on an objective standard is, therefore, demanded. Purpose: To evaluate the quantification of magnifying NBI findings of colorectal lesions and utility of computer-assisted automatic identification system for NBI classificationMethod: In this study, Sano's classification which is the original colorectal NBI classification was further broadly divided into three classes A: CP type I, B: CP type IIϩCP type IIIA and C: CP type IIIB. First, the following computer-assisted procedures were performed using front-view magnifying NBI images appropriate for each class (A: 5 images, B: 10 images, C: 6 images): determination of region of interest (ROI), conversion of images into grayscale images, visualization of rough vessels through binarization using the moving average method, deletion of all colors except the vessel color and removal of isolated points and holes. Subsequently, characteristics such as average visualized vessel width, average visualized vessel length, total visualized vessel length, average visualized vessel concentration and the fractal dimension were used to extract significant quantitative characteristics from these. Moreover, the images for the region of interest were added, and a total of 37 images (A: 11 images, B: 18 images, C: 8 images) were distinguished using an automatic identification system. In addition, identifications of the images of B and C alone were conducted. Results: As a result of the evaluation of each quantitative characteristic in the 21 images of ROI, significant differences were observed among several classes in three quantitative characteristics: average visualized vessel length, total visualized vessel length, and average visualized vessel concentration. As a result of the identification performed on a total of 37 images using the above quantitative characteristics, the identification rate of three classes was 81.1%. In addition, the identification rate between B and C was 96.2%. Conclusion: Admissible identification rates were obtained for the quantification and automatic identification of the magnifying colorectal NBI findings. Our future challenges are to improve the reliability of each quantitative characteristic and to seek for new quantitative characteristics. It can be expected that once automatic identification procedure with high accuracy is achieved, it will contribute to the education of less-experienced endoscopists.
Gastrointestinal Endoscopy, 2009
Gastrointestinal Endoscopy, 2009
Endoscopy, Jan 8, 2018
Sessile serrated polyps (SSPs) are important precursors of colorectal carcinoma and interval can... more Sessile serrated polyps (SSPs) are important precursors of colorectal carcinoma and interval cancer. Large SSPs (≥ 20 mm) outside the definition of serrated polyposis syndrome (SPS) have not been studied in comparison with SPS. We aimed to describe the characteristics of patients with large SSPs in this context. Patients with at least one SSP (≥ 20 mm) were eligible. Data from three consecutive colonoscopies were used to compare clinical and endoscopic characteristics in three patient groups: SPS, a solitary large SSP, and patients with at least two SSPs without fulfilling the criteria for SPS (oligo-SSP). Data on the diagnostic colonoscopy were collected retrospectively, whereas the remaining data was collected prospectively. 67/146 patients (45.9 %) had SPS, 53/146 (36.3 %) had a solitary SSP, and 26/146 (17.8 %) were categorized as oligo-SSP. Personal (16.4 %, 9.4 %, and 11.5 %, respectively) and family (17.9 %, 17.0 %, and 23.1 %, respectively) history of colorectal carcinoma...
Gastrointestinal endoscopy, Jan 5, 2018
EMR of sessile periappendiceal laterally spreading lesions (PA-LSLs) is technically demanding bec... more EMR of sessile periappendiceal laterally spreading lesions (PA-LSLs) is technically demanding because of poor endoscopic access to the appendiceal lumen and the thin colonic wall at the base of the cecum. We aimed to assess the feasibility and safety of EMR for PA-LSLs. Consecutive LSLs ≥20 mm and PA-LSLs ≥10 mm detected at 3 academic endoscopy centers from September 2008 until January 2017 were eligible. Prospective patient, procedural, and lesion data were collected. PA-LSLs were compared with LSLs in other colonic locations. Thirty-eight PA-LSLs were compared with 1721 LSLs. Referral for surgery without an attempt at EMR was more likely with PA-LSLs (28.9% vs 5.1%, P < .001), and those that involved a greater percentage of the appendiceal orifice (AO) were less likely to be attempted (P = .038). Most PA-LSLs (10/11) were not attempted because of deep extension into the appendiceal lumen; 2 of 11 of these surgical specimens contained invasive cancer. Once attempted, complete cl...
Gastrointestinal endoscopy, Jan 6, 2018
Wire-guided biliary cannulation has been demonstrated to improve cannulation rates and reduce pos... more Wire-guided biliary cannulation has been demonstrated to improve cannulation rates and reduce post-ERCP pancreatitis (PEP), but the impact of wire caliber has not been studied. This study compares successful cannulation rates and ERCP adverse events using a 0.025-inch and 0.035-inch guidewire. A randomized, single blinded, prospective multi-center trial at 9 high volume tertiary referral centers in the Asia Pacific region was performed. Patients with an intact papilla and conventional anatomy who did not have head of pancreas or ampullary malignancy undergoing ERCP were recruited. ERCP was performed using a standardized cannulation algorithm and patients were randomized to either a 0.025-inch or 0.035-inch guidewire. The primary outcomes of the study were successful wire guided cannulation and incidence of PEP. Overall successful cannulation and ERCP adverse events were also studied. Seven hundred ten patients were enrolled in the study. Primary wire-guided biliary cannulation rate ...
Endoscopy, Jan 25, 2018
The SMSA (size, morphology, site, access) polyp scoring system is a method of stratifying the di... more The SMSA (size, morphology, site, access) polyp scoring system is a method of stratifying the difficulty of polypectomy through assessment of four domains. The aim of this study was to evaluate the ability of SMSA to predict critical outcomes of endoscopic mucosal resection (EMR). We retrospectively applied SMSA to a prospectively collected multicenter database of large colonic laterally spreading lesions (LSLs) ≥ 20 mm referred for EMR. Standard inject-and-resect EMR procedures were performed. The primary end points were correlation of SMSA level with technical success, adverse events, and endoscopic recurrence. 2675 lesions in 2675 patients (52.6 % male) underwent EMR. Failed single-session EMR occurred in 124 LSLs (4.6 %) and was predicted by the SMSA score (P < 0.001). Intraprocedural and clinically significant postendoscopic bleeding was significantly less common for SMSA 2 LSLs (odds ratio [OR] 0.36, P < 0.001 and OR 0.23, P < 0.01) and SMSA 3 LSLs (OR 0.41, P <...
Endoscopy, Jan 11, 2017
Background and aims Non-lifting large laterally spreading colorectal lesions (LSLs) are challengi... more Background and aims Non-lifting large laterally spreading colorectal lesions (LSLs) are challenging to resect endoscopically and often necessitate surgery. A safe, simple technique to treat non-lifting LSLs endoscopically with robust long-term outcomes has not been described. Methods In this single-center prospective observational study of consecutive patients referred for endoscopic mucosal resection (EMR) of LSLs ≥ 20 mm, LSLs not completely resectable by snare because of non-lifting underwent standardized completion of resection with cold-forceps avulsion and adjuvant snare-tip soft coagulation (CAST). Scheduled surveillance colonoscopies were performed at 4 - 6 months (SC1) and 18 months (SC2). Primary outcomes were endoscopic evidence of adenoma clearance and avoidance of surgery. The secondary outcome was safety. Results From January 2012 to October 2016, 540 lifting LSLs (82.2 %) underwent complete snare excision at EMR. CAST was required for complete removal in 101 non-lifti...
Endoscopy International Open, 2019
Background and study aims Colonic angioectasia are the most common vascular lesions in the gastro... more Background and study aims Colonic angioectasia are the most common vascular lesions in the gastrointestinal tract and are among the most common causes for chronic or recurrent lower gastrointestinal bleeding. Endoscopic treatment involves a variety of techniques, all of which focus on destruction of the mucosal abnormality. However, recurrent bleeding after endoscopic treatment is common, with more than one treatment frequently necessary. We report a technique for definitive treatment of colonic angioectasia by targeting the feeding submucosal vessel. Patients and methods Analogous to endoscopic mucosal resection, a submucosal injection is made beneath the target lesion which is then removed by electrocautery snare resection of the mucosal lesion. The exposed feeding vessel is then destroyed by application of coagulation current. The resection defect is closed by clips. Results Six patients with a total of 14 colonic angioectasia were treated over the study period. All lesions were ...
Modern Pathology, 2020
Endoscopic resection (ER) allows optimal staging with potential cure of early-stage luminal malig... more Endoscopic resection (ER) allows optimal staging with potential cure of early-stage luminal malignancies while maintaining organ preservation. ER and surgery are non-competing but complementary therapeutic options. In addition, histological examination of ER specimens can either confirm or refine the pre-procedure diagnosis. ER is used for the treatment of Barrett's related early carcinomas and dysplasias, early-esophageal squamous cell carcinomas and dysplasias, early gastric carcinomas and dysplasia, as well as low-risk submucosal invasive carcinomas (LR-SMIC) and, large laterally spreading adenomas of the colon. For invasive lesions, histological risk factors predict risk of lymph node metastasis and residual disease at the ER site. Important pathological risk factors predictive of lymph node metastasis are depth of tumor invasion, poor differentiation, and lymphovascular invasion. Complete resection with negative margins is critical to avoid local recurrences. For non-invasive lesions, complete resection is curative. Therefore, a systematic approach for handling and assessing ER specimens is recommended to evaluate all above key prognostic features appropriately. Correct handling starts with pinning the specimen before fixation, meticulous macroscopic assessment with orientation of appropriate margins, systematic sectioning, and microscopic assessment of the entire specimen. Microscopic examination should be thorough for accurate assessment of all pathological risk factors and margin assessment. Site-specific issues such as duplication of muscularis mucosa of the esophagus, challenges of assessing ampullectomy specimens and site-specific differences of staging of early carcinomas throughout the gastrointestinal tract (GI) tract should be given special consideration. Finally, a standard, comprehensive pathology report that allows optimal staging with potential cure of early-stage malignancies or better stratification and guidance for additional treatment should be provided.
Medical Journal of Australia, 2018
VideoGIE : an official video journal of the American Society for Gastrointestinal Endoscopy, 2018
Gut and liver, Jan 11, 2017
Serrated polyps are important contributors to the burden of colorectal cancers (CRC). These lesio... more Serrated polyps are important contributors to the burden of colorectal cancers (CRC). These lesions were once considered to have no malignant potential, but currently up to 30% of all CRC are recognized to arise from the serrated neoplasia pathway. The primary premalignant lesions are sessile serrated adenomas/polyps (SSA/Ps), although traditional serrated adenomas are relatively uncommon. Compared to conventional adenomas, SSA/Ps are morphologically subtle with indistinct borders, may be difficult to detect endoscopically, are more prevalent than previously thought, are associated with synchronous and metachronous advanced neoplasia, and have a higher risk of incomplete resection. Although many lesions remain "dormant," progressive disease is associated with the development of dysplasia and more rapid progression to CRC. As a result, SSA/Ps are strongly implicated in the development of interval cancers. These factors represent unique challenges that require a meticulous a...
Endoscopy International Open, 2016
United European Gastroenterology Journal, 2017
Background: Endoscopic therapy, including by radiofrequency ablation (RFA) or endoscopic mucosal ... more Background: Endoscopic therapy, including by radiofrequency ablation (RFA) or endoscopic mucosal resection (EMR), is first line treatment for Barrett's esophagus (BE) with high grade dysplasia (HGD) or intramucosal cancer (IMC) and may be appropriate for some patients with low grade dysplasia (LGD). Objective: To investigate the molecular effects of endotherapy. Methods: mRNA expression of 16 genes significantly associated with different BE stages was measured in paired pre-treatment BE tissues and post-treatment neo-squamous biopsies were obtained from 36 patients treated by RFA (19 patients, 3 IMC, 4 HGD, 12 LGD) or EMR (17 patients, 4 IMC, 13 HGD). EMR was performed prior to RFA in 8 patients. Normal squamous esophageal tissues were from 20 control individuals. Results: Endoscopic therapy resulted in significant change towards the normal squamous expression profile for all genes. The neo-squamous expression profile was significantly different to the normal control profile for 11 of 16 genes. Conclusion: Endotherapy results in marked changes in mRNA expression, with replacement of the disordered BE dysplasia or IMC profile with a more "normal" profile. The neo-squamous mucosa was significantly different to the normal control squamous mucosa for most genes. The significance of this finding is uncertain but it may support continued endoscopic surveillance after successful endotherapy.
Endoscopy, Jan 4, 2015
Background and aims: Complete endoscopic resection (CER) of short-segment Barrett's esophagus... more Background and aims: Complete endoscopic resection (CER) of short-segment Barrett's esophagus with high grade dysplasia (HGD) and early esophageal adenocarcinoma (EEA) is a precise staging tool and achieves durable disease control. The major drawback is development of post-endoscopic resection esophageal stricture (PERES). No effective therapy to prevent PERES has been described. Viscous budesonide slurry (VBS) may have a role in the prevention of PERES by suppressing the post-CER inflammatory process. The study aim was to evaluate the efficacy of VBS for the prevention of PERES. Methods: Prospective data were collected on patients referred for CER of HGD or EEA. After January 2012, patients routinely received VBS (two 0.5-mg/2-mL budesonide respules mixed with sucralose) twice daily for 6 weeks following each stage of the CER schedule. All patients received high dose proton pump inhibitor therapy for the duration of CER and the following 3 months. Patients had no other interven...
Clinical Gastroenterology and Hepatology, 2015
BACKGROUND & AIMS: Use of precut sphincterotomy during endoscopic retrograde cholangiopancreatogr... more BACKGROUND & AIMS: Use of precut sphincterotomy during endoscopic retrograde cholangiopancreatography (ERCP) can increase the odds for cannulation success but is associated with increased risk of post-ERCP pancreatitis. Earlier, rather than delayed, use of precut sphincterotomy for cases with difficult biliary access might reduce this risk. We performed a meta-analysis of randomized controlled trials to determine how early use of precut sphincterotomy affects the risk of pancreatitis and rate of cannulation success compared with persistent standard cannulation. METHODS: We searched MEDLINE, EMBASE, and the Cochrane central register of controlled trials, along with meeting abstracts, through August 2014 for randomized controlled trials in which early precut sphincterotomy was compared with persistent standard cannulation in adults with difficult biliary access. Outcomes considered included primary cannulation success, overall cannulation success, incidence of post-ERCP pancreatitis, and overall adverse event rate. Findings from a random-effects model were expressed as pooled risk ratios (RRs) with 95% confidence intervals (CIs). RESULTS: We analyzed data from 5 studies (523 participants). The incidence of post-ERCP pancreatitis and success of overall cannulation did not differ significantly between the early precut and persistent standard therapy groups. Early use of precut sphincterotomy was associated with increased odds for primary cannulation success (RR, 1.32; 95% CI, 1.04-1.68). In subgroup analysis of studies that involved only fully qualified biliary endoscopists (not fellows), we found a significant reduction in risk of pancreatitis among patients receiving early precut vs the standard technique (RR, 0.29; 95% CI, 0.10-0.86). CONCLUSION: Compared with standard therapy, early use of precut sphincterotomy did not increase the risk of post-ERCP pancreatitis in a meta-analysis. When the procedure is performed by qualified biliary endoscopists, early precut can reduce the risk of post-ERCP pancreatitis. Rates of primary cannulation increase with early precut. Further studies are needed to confirm these findings.
Gastroenterology & hepatology, 2011
G&H Is bleeding a common complication of endoscopic mucosal resection? MJB Significant post-endos... more G&H Is bleeding a common complication of endoscopic mucosal resection? MJB Significant post-endoscopic mucosal resection (EMR) bleeding (PEB) is defined as bleeding that requires medical attention (ie, presentation to the emergency room and/or hospital admission). PEB occurs in 5-7% of colonic EMR cases. The need for medical assessment usually leads to hospital admission and ancillary investigations, including repeat colonoscopy and, less frequently, blood transfusion. The risk of developing PEB diminishes the advantages of EMR as a safe, cost-effective, minimally invasive therapy for advanced mucosal neoplasia of the colon.
Gastrointestinal Endoscopy, 2009
A 32-year-old man developed right upper quadrant (RUQ) pain, fever, and jaundice 10 days after la... more A 32-year-old man developed right upper quadrant (RUQ) pain, fever, and jaundice 10 days after laparotomy and resection of a 3-cm jejunal GI stromal tumor (GIST). Abdominal US revealed a dilated common bile duct (CBD), with biliary sludge as the likely cause for cholangitis. ERCP showed a dilated CBD with irregular ridging or serration of the CBD wall (A). After sphincterotomy, purulent bile and thick sludge were cleared. A 10F plastic stent was placed to ensure continued adequate drainage. Follow-up ERCP at 6 weeks showed complete resolution of the previous cholangiographic abnormalities (B). A 65-year-old man with fever, jaundice, and RUQ pain, unresponsive to parenteral antibiotics, underwent an emergency ERCP. Cholangiography revealed dilatation and irregular ridging or serration of the CBD wall (C). After sphincterotomy, purulent bile as well as small CBD calculi were cleared from the duct. A double-pigtail 7F stent was inserted for biliary drainage. Repeat ERCP after 6 weeks revealed resolution of the documented bile-duct-wall abnormality; however, a previously unapparent distal CBD stricture was found, and, subsequently, the diagnosis of cholangiocarcinoma was made (D).
Gastrointestinal Endoscopy, 2011
possibility of interobserver variance in NBI classification for colorectal lesions. Interpretatio... more possibility of interobserver variance in NBI classification for colorectal lesions. Interpretation of the magnifying NBI findings based on an objective standard is, therefore, demanded. Purpose: To evaluate the quantification of magnifying NBI findings of colorectal lesions and utility of computer-assisted automatic identification system for NBI classificationMethod: In this study, Sano's classification which is the original colorectal NBI classification was further broadly divided into three classes A: CP type I, B: CP type IIϩCP type IIIA and C: CP type IIIB. First, the following computer-assisted procedures were performed using front-view magnifying NBI images appropriate for each class (A: 5 images, B: 10 images, C: 6 images): determination of region of interest (ROI), conversion of images into grayscale images, visualization of rough vessels through binarization using the moving average method, deletion of all colors except the vessel color and removal of isolated points and holes. Subsequently, characteristics such as average visualized vessel width, average visualized vessel length, total visualized vessel length, average visualized vessel concentration and the fractal dimension were used to extract significant quantitative characteristics from these. Moreover, the images for the region of interest were added, and a total of 37 images (A: 11 images, B: 18 images, C: 8 images) were distinguished using an automatic identification system. In addition, identifications of the images of B and C alone were conducted. Results: As a result of the evaluation of each quantitative characteristic in the 21 images of ROI, significant differences were observed among several classes in three quantitative characteristics: average visualized vessel length, total visualized vessel length, and average visualized vessel concentration. As a result of the identification performed on a total of 37 images using the above quantitative characteristics, the identification rate of three classes was 81.1%. In addition, the identification rate between B and C was 96.2%. Conclusion: Admissible identification rates were obtained for the quantification and automatic identification of the magnifying colorectal NBI findings. Our future challenges are to improve the reliability of each quantitative characteristic and to seek for new quantitative characteristics. It can be expected that once automatic identification procedure with high accuracy is achieved, it will contribute to the education of less-experienced endoscopists.
Gastrointestinal Endoscopy, 2009
Gastrointestinal Endoscopy, 2009
Endoscopy, Jan 8, 2018
Sessile serrated polyps (SSPs) are important precursors of colorectal carcinoma and interval can... more Sessile serrated polyps (SSPs) are important precursors of colorectal carcinoma and interval cancer. Large SSPs (≥ 20 mm) outside the definition of serrated polyposis syndrome (SPS) have not been studied in comparison with SPS. We aimed to describe the characteristics of patients with large SSPs in this context. Patients with at least one SSP (≥ 20 mm) were eligible. Data from three consecutive colonoscopies were used to compare clinical and endoscopic characteristics in three patient groups: SPS, a solitary large SSP, and patients with at least two SSPs without fulfilling the criteria for SPS (oligo-SSP). Data on the diagnostic colonoscopy were collected retrospectively, whereas the remaining data was collected prospectively. 67/146 patients (45.9 %) had SPS, 53/146 (36.3 %) had a solitary SSP, and 26/146 (17.8 %) were categorized as oligo-SSP. Personal (16.4 %, 9.4 %, and 11.5 %, respectively) and family (17.9 %, 17.0 %, and 23.1 %, respectively) history of colorectal carcinoma...
Gastrointestinal endoscopy, Jan 5, 2018
EMR of sessile periappendiceal laterally spreading lesions (PA-LSLs) is technically demanding bec... more EMR of sessile periappendiceal laterally spreading lesions (PA-LSLs) is technically demanding because of poor endoscopic access to the appendiceal lumen and the thin colonic wall at the base of the cecum. We aimed to assess the feasibility and safety of EMR for PA-LSLs. Consecutive LSLs ≥20 mm and PA-LSLs ≥10 mm detected at 3 academic endoscopy centers from September 2008 until January 2017 were eligible. Prospective patient, procedural, and lesion data were collected. PA-LSLs were compared with LSLs in other colonic locations. Thirty-eight PA-LSLs were compared with 1721 LSLs. Referral for surgery without an attempt at EMR was more likely with PA-LSLs (28.9% vs 5.1%, P < .001), and those that involved a greater percentage of the appendiceal orifice (AO) were less likely to be attempted (P = .038). Most PA-LSLs (10/11) were not attempted because of deep extension into the appendiceal lumen; 2 of 11 of these surgical specimens contained invasive cancer. Once attempted, complete cl...
Gastrointestinal endoscopy, Jan 6, 2018
Wire-guided biliary cannulation has been demonstrated to improve cannulation rates and reduce pos... more Wire-guided biliary cannulation has been demonstrated to improve cannulation rates and reduce post-ERCP pancreatitis (PEP), but the impact of wire caliber has not been studied. This study compares successful cannulation rates and ERCP adverse events using a 0.025-inch and 0.035-inch guidewire. A randomized, single blinded, prospective multi-center trial at 9 high volume tertiary referral centers in the Asia Pacific region was performed. Patients with an intact papilla and conventional anatomy who did not have head of pancreas or ampullary malignancy undergoing ERCP were recruited. ERCP was performed using a standardized cannulation algorithm and patients were randomized to either a 0.025-inch or 0.035-inch guidewire. The primary outcomes of the study were successful wire guided cannulation and incidence of PEP. Overall successful cannulation and ERCP adverse events were also studied. Seven hundred ten patients were enrolled in the study. Primary wire-guided biliary cannulation rate ...
Endoscopy, Jan 25, 2018
The SMSA (size, morphology, site, access) polyp scoring system is a method of stratifying the di... more The SMSA (size, morphology, site, access) polyp scoring system is a method of stratifying the difficulty of polypectomy through assessment of four domains. The aim of this study was to evaluate the ability of SMSA to predict critical outcomes of endoscopic mucosal resection (EMR). We retrospectively applied SMSA to a prospectively collected multicenter database of large colonic laterally spreading lesions (LSLs) ≥ 20 mm referred for EMR. Standard inject-and-resect EMR procedures were performed. The primary end points were correlation of SMSA level with technical success, adverse events, and endoscopic recurrence. 2675 lesions in 2675 patients (52.6 % male) underwent EMR. Failed single-session EMR occurred in 124 LSLs (4.6 %) and was predicted by the SMSA score (P < 0.001). Intraprocedural and clinically significant postendoscopic bleeding was significantly less common for SMSA 2 LSLs (odds ratio [OR] 0.36, P < 0.001 and OR 0.23, P < 0.01) and SMSA 3 LSLs (OR 0.41, P <...
Endoscopy, Jan 11, 2017
Background and aims Non-lifting large laterally spreading colorectal lesions (LSLs) are challengi... more Background and aims Non-lifting large laterally spreading colorectal lesions (LSLs) are challenging to resect endoscopically and often necessitate surgery. A safe, simple technique to treat non-lifting LSLs endoscopically with robust long-term outcomes has not been described. Methods In this single-center prospective observational study of consecutive patients referred for endoscopic mucosal resection (EMR) of LSLs ≥ 20 mm, LSLs not completely resectable by snare because of non-lifting underwent standardized completion of resection with cold-forceps avulsion and adjuvant snare-tip soft coagulation (CAST). Scheduled surveillance colonoscopies were performed at 4 - 6 months (SC1) and 18 months (SC2). Primary outcomes were endoscopic evidence of adenoma clearance and avoidance of surgery. The secondary outcome was safety. Results From January 2012 to October 2016, 540 lifting LSLs (82.2 %) underwent complete snare excision at EMR. CAST was required for complete removal in 101 non-lifti...