Impact of Mobile Endoscopy Unit for Rendering Gastrointestinal Endoscopy Services at Two Community Health Centers in Western India

Background Patients with gastrointestinal (GI) symptoms in remote areas do not have access to standard medical care with the issues related to cost of medical care, transportation, health literacy, lack of healthcare insurance—all preventing healthcare access in a timely manner. To overcome this, we designed a mobile endoscopy van with the intent to provide free essential medical services to the rural population. Methods This is a retrospective study of patients with predominantly upper GI symptoms at two community health centers (each 2 days camp). This is an audit of endoscopy findings in a community set up using a Mobile Endoscopy Unit (MEU). Patients' details were collected in a pre-designed questionnaire. Only those patients with alarm symptoms and suspicion of any pathological state underwent esophagogastroduodenoscopy (EGD) in MEU. Data analysis was done using descriptive statistics. Results A total of 724 patients (424 [58.5%] males; mean [SD] age 48.5 [5.2] years) were included. The commonest presenting symptom was heartburn in 377 (52.1%) patients. The median duration of symptoms was 6.5 (range: 2–36) months. Gastroesophageal reflux disease was seen in 16 (6.8%) patients, ulceroproliferative growth was noted in the stomach in 3 (1.3%) patients. Eighteen (7.6%) patients had a positive rapid urease test and received Helicobacter pylori eradication therapy. The most commonly prescribed drugs were proton-pump inhibitors in 692 (95.6%) patients. Nine (1.2%) patients had chronic liver disease secondary to alcoholism and were counseled for abstinence. All procedures were safely performed without any immediate adverse events. Conclusions Community outreach strategies such as the use of mobile endoscopy unit were found to be very useful in the diagnosis of GI symptoms. More research is needed in low-income countries to treat complex pathological states in rural patients.

Esophageal Motility Disorders: Are We Missing in Our Busy Endoscopy Practice?

Esophageal motility disorders (EMDs) form a significant part of a busy endoscopist's practice. Endoscopy plays an all-encompassing role in the diagnosis and management of EMDs including achalasia cardia. The focus on in-vogue third-space endoscopic procedures such as per-oral endoscopic myotomy often digresses the important role of endoscopy. Endoscopic evaluation forms the part of standard first-line evaluation of any dysphagia and serves to rule out a secondary cause such as an esophagogastric junction malignancy and eosinophilic esophagitis. Moreover, endoscopic evaluation may itself provide corroborative evidence that may contribute to the diagnosis of the motility disorder. Achalasia cardia may present with a wide spectrum of endoscopic findings from being entirely normal and the well-known and pathognomonic dilated sigmoid-shaped esophagus with food residue, to lesser-known ornate signs. The evidence on the role of endosonography in EMDs is conflicting and largely restricted to evaluation of pseudoachalasia. High-resolution manometry (HRM) remains the gold standard in the diagnosis of EMDs. Endoscopists must also keep abreast of the latest iteration of the Chicago classification version 4.0, which differs significantly from its predecessor in being more stringent in making diagnosis of esophagogastric junction outflow obstruction and disorders of peristalsis since these manometric findings may be seen in normal individuals and may be mimicked by opioid use and gastroesophageal reflux. The latest rendition also includes the use of provocative maneuvers and testing in both supine and sitting posture. Despite being the gold standard, there are certain lacunae in the use and interpretation of the Chicago classification of which the users should be well aware. Emerging technologies such as functional lumen imaging probe and planimetry, and timed barium esophagogram fill the lacuna in diagnosis of these motility disorders, which at times is beyond the resolution of HRM.

Reprocessing and Reuse of Endoscopic Accessories

Endoscopic accessories are critical devices that breach sterile body sites. They have unique reprocessing difficulties compared with other medical and surgical devices because of their complex structure, narrow lumens, thermolabile construction materials, and application through a semicritical endoscopic device. In addition, there is the possibility of functional derangement of endoscopic accessories with reprocessing, and most are now marketed as single-use devices. While reprocessing of endoscopes has been the subject of numerous societal guidelines, the issue of reprocessing endoscopic accessories and ancillary detachable devices used with the endoscope is seldom addressed. We summarize the existing data on the cleaning and reprocessing of endoscopic accessories.

Safety and Efficacy of Early Endotherapy in Management of Pancreatic Ascites: Western Indian Experience.

Background Pancreatic ascites is rare but a known complication of pancreatitis. We aimed to study the timings, safety, and efficacy of therapeutic approaches in its management and the outcomes. Methods We retrospectively studied patients with pancreatic ascites managed in the past 5 years at a single tertiary care center. Therapeutic approaches included conservative therapy, early endoscopic therapy, and surgery. We used descriptive statistics to summarize characteristics of the study population, and performed univariate and binary logistic regression analyses to compare treatment outcomes. Results Of the 125 patients screened, 70 (male, 81.4%) were included. Disruption in the pancreatic duct (PD) was seen in 51.4% of patients on magnetic resonance cholangiopancreatography (MRCP) and 73.3% of patients on endoscopic retrograde cholangiopancreatography (ERCP). The PD in the body region (46.7%) was the most frequent site of disruption. Early endotherapy included a stent bridging the disruption site in 63.3% of patients and sphincterotomy in 76.7% of patients with a median time to ERCP from symptom onset being 8.5 days. The success rate in early endotherapy was 81.7%, while the recurrence rate was 8%. For conservative therapy only, the success rate was 60% with recurrence in two-thirds. The variables crucial in the success of endotherapy were a partial disruption (p < 0.001), ductal disruption site (p = 0.004), sphincterotomy (p = 0.013), and a bridging stent (p = 0.001). Significant pancreatic necrosis (p < 0.001) and intraductal calculi (p = 0.002) were the factors responsible for failure in endotherapy. Conclusions Early endotherapy is safe and effective in the treatment of pancreatic ascites. The efficacy of endotherapy is augmented by PD stenting combined with pancreatic sphincterotomy and a bridging stent.

Novel Resection System for Direct Endoscopic Necrosectomy of Walled-Off Pancreas Necrosis: Have We Conquered the Final Frontier?

Surgical necrosectomy has been the traditional management for pancreatic necrosis and is done using blunt dissection. However, lack of dedicated endoscopic accessories has been a major limitation in direct endoscopic necrosectomy (DEN). Standard endoscopic accessories cannot effectively remove large necrotic material. Also, diameter of instrument channel of the endoscope limits the ability to use large-diameter graspers that can remove large chunks of necrotic material. In this news, we discuss a recent study that has evaluated a new powered endoscopic debridement system for DEN.

Recent Endoscopic Ultrasound-Related Publications With Potential to Influence Clinical Practice

The field of endoscopic ultrasound (EUS) has evolved significantly over the last two decades from being a tool of only diagnostic purpose to tissue acquisition and now therapeutic potential. There have been several important publications in the field of EUS in the last few years, which had a major impact in the clinical management of various gastrointestinal disorders. In this review, we discuss four such articles that in our opinion will significantly impact the role of EUS in treating various conditions. The first article is a randomized controlled trial comparing EUS-guided gall bladder drainage with percutaneous gall bladder drainage for high-risk acute cholecystitis. The second article is a randomized controlled trial comparing EUS versus minimally invasive surgery for necrotizing pancreatitis. The third article is a novel human study of EUS-guided portal pressure measurement in patients with portal hypertension. The last article is also a randomized controlled trial evaluating the role of rapid on-site evaluation for EUS-guided fine needle biopsy in solid pancreatic lesions.

Endoscopic Ultrasonography-Specific Stents

The evolution of the endoscopic ultrasonography (EUS) technique has necessitated the development of EUS-specific accessories and stents. In the earlier period, EUS-guided interventions mostly relied on borrowed accessories and stents from therapeutic endoscopy in particular ERCP. Traditional stents do not serve the purpose of EUS-guided transluminal stenting in all cases due to the length of the stent, no anchoring mechanism, and chance of migration. From 2011 onward, several EUS-specific stents became available, bringing a paradigm shift in interventional EUS. This article reviews current EUS-specific stents, indications, strengths, and weaknesses.

Colonic Stenting Using Side-Viewing Endoscope: A Case Report

Colonic self-expandable metal stents (SEMS) are widely used as palliation for malignant obstruction. The conventional method involves using a forward-viewing endoscope as part of the procedure. Sometimes, however, the sharp angle of the stricture poses difficulty in evaluating the stricture, so a guidewire is placed across the stricture. Here, we present a case where a side-viewing endoscope was employed for colonic stent placement and propose its use in patients with sharp bends to increase success.