How to Improve Reprocessing of Flexible Endoscopes Nationwide? Data from the German Colorectal Cancer Screening Program

Background and Aims. International studies revealed prevalences of around 50% of microbiological contaminations in reprocessed flexible endoscopes. In Germany a system was installed where the qualification for refund for colonoscopies was made conditional on successfully passing twice annually a microbiological surveillance test of reprocessed endoscopes. This study is an implementation and outcome evaluation as well as a general discussion of the quality assessment assurance in colonoscopy in Germany. Methods. German data from 2003–2008 were analysed: number of endoscopic units performing therapeutic and/or screening colonoscopies; results of all microbiological surveillance tests of reprocessing quality; number of failed surveillance tests and retests; number of qualifications for refund from the public health system cancelled due to repeated failure of microbiological surveillance tests. Results. After the introduction of the quality assessment assurance, the percentage of failed microbiological surveillance tests dropped significantly and steadily from close to 17% to below 5%. Conclusions. This study evidences (1st) the successful implementation of the quality assessment assurance in Germany and (2nd) a substantial improvement in the quality of reprocessing flexible endoscopes achieved by these measures.

Safety and Effectiveness of Endoscopic Savary-Gillaard Bougies Dilation in Moroccan Plummer-Vinson Syndrome Patients

The authors aimed to better define the clinical, biological, radiological, endoscopic, and evolutionary characteristics of patients presenting with Plummer-Vinson syndrome after endoscopic dilation and medical treatment in this study. There were 41 cases of Plummer-Vinson syndrome listed. All these patients presented dysphagia associated to anemia, and all have benefited endoscopic dilation and iron supplementation with a good clinical and biological course in 100% of cases. The Plummer-Vinson syndrome is a rare entity. The treatment, based essentially on endoscopic dilations, is effective and safe.

Influence of Helicobacter pylori Infection on the Small Intestinal Mucosa

Background/Aims. To investigate the role of Helicobacter pylori infection in the development of enteritis (small intestinal mucosal injury). Methodology. Between April 2007 and January 2013, 99 patients undergoing capsule endoscopy (CE) were tested for anti-H. pylori immunoglobulin G antibody (Hp-IgG) using an enzyme-linked immunosorbent assay (ELISA). None of the patients had been treated for H. pylori infection or diagnosed as having Crohn’s disease or any other clinically apparent small intestinal disorders prior to the CE. Results. The overall Hp-IgG-positive rate was 26.3%. The incidence of enteritis, as diagnosed by CE, tended to be lower in the Hp-IgG-positive patients (23.1%) than in the Hp-IgG-negative patients (38.4%) (). When patients receiving aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), well-known causes of enteritis, were excluded, the incidence of enteritis in the Hp-IgG-positive patients (11.7%) was significantly lower than that in the Hp-IgG-negative patients (43.7%) (). A binomial logistic regression analysis revealed a significant negative relationship between Hp-IgG positivity and the presence of enteritis in patients receiving neither aspirin nor NSAIDs (). Conclusions. Our data indicated that H. pylori positivity was inversely associated with the prevalence of enteritis.

Routine Duodenal Biopsies in the Absence of Endoscopic Markers of Celiac Disease Are Not Useful: An Observational Study

Background. European studies have shown the utility of limiting endoscopic biopsies to diagnose celiac disease (CD) to patients that have high-risk symptoms or present with positive serology. However, many centers in the U.S. have open access endoscopy. Patients are referred without prior serologic testing, and endoscopists often decide whether or not to biopsy at the time of procedure. Aims. Evaluate the yield of duodenal biopsies for the diagnosis of CD in patients undergoing upper endoscopy without prior serologic testing. Methods. This retrospective study evaluated the frequency of CD diagnosis based duodenal biopsies. Researchers were interested in the yield of endoscopic stigmata findings in patients with high-risk symptoms versus low risk. Results. Eight hundred and ten patients met entry criteria at the Cleveland Clinic Florida between 2004 and 2008; 320 presented with high-risk symptoms; and 490 low risk. Sixty-one (7.5%) displayed endoscopic stigmata, and 10/61 (16.3%) were diagnosed with CD. Only patients who exhibited endoscopic stigmata were later diagnosed based on histologic findings. The presence of endoscopic stigmata greatly increased the probability of diagnosing CD, with a positive likelihood ratio of 15.6. Conclusions. When performing upper endoscopy without known serological markers for CD, clinicians should limit duodenal biopsies to patients with high-risk symptoms or endoscopic stigmata.

The Diagnostic Yield of Navigational Bronchoscopy Performed with Propofol Deep Sedation

Objective. To describe the diagnostic yield of electromagnetic navigation bronchoscopy (ENB) utilizing propofol for procedural deep sedation. Methods. We conducted a structured retrospective analysis of the medical records of patients who underwent ENB with propofol for the evaluation of pulmonary nodules and masses. We analyzed the relationships between lesion size and location, variance (CT-to-body divergence), and positron emission tomography findings on diagnostic yield. Diagnoses were established by histopathological evaluation and clinical-radiographic followup. Results. 41 patients underwent ENB during the study period. The overall diagnostic yield was 89% (42 of 47 target lesions). Among the 42 positive specimens, the diagnoses were squamous cell carcinoma (n=10), adenocarcinoma (n=14), small cell carcinoma (n=2), adenocarcinoma in situ (n=2), coccidioidomycosis (n=1), and inflammatory processes (n=13). Average lesion size was 3.01±0.21 cm and variance 3.6±0.15 mm. The diagnostic yield was greater when the lesion size was >4 cm (100%) and when variance was ≤4 mm (91% versus 87%, P=0.003). Conclusion. The diagnostic yield of ENB utilizing propofol for procedural deep sedation at our center was excellent. ENB with deep sedation may result in superior diagnostic yield compared with ENB performed with moderate sedation.

Practice Trends in the Surgical Management of Renal Tumors in an Academic Medical Center in the Past Decade

Objectives. To evaluate the trends of surgical treatment of the renal tumor in an academic medical center. Methods. Between 2001 and 2010, 505 were treated surgically at the Federal University of Sao Paulo for renal tumors. The following variables were observed and analyzed according to their evolution through time: frequency and types of surgeries performed, operative time, hospital stay, and warm ischemia time for partial nephrectomy. Results. An increase in the frequency of laparoscopic radical nephrectomies, open partial nephrectomies, and laparoscopic partial nephrectomies was observed when comparing the periods from 2001 to 2005 (4.3%, 2.6%, and 12.6%, resp.) and from 2006 to 2010 (13.2%, 18.6%, and 20.2%, resp.; ). The average of operative time, hospital stay, and tumor size diminished (from 211.7 to 177.17 minutes, from 5.52 to 4.22 days, and from 6.72 to 5.29 cm, resp.) when compared to the periods from 2001 to 2005 and from 2006 to 2010 (, , resp.). Conclusion. As time goes by, there has been a significant reduction in the hospital stay time, surgery time, and size of renal tumor in patients treated surgically. The frequencies of minimally invasive and nephron-sparing surgeries have increased over the last years.

Optimal Positioning for ERCP: Efficacy and Safety of ERCP in Prone versus Left Lateral Decubitus Position

Background. ERCP is customarily performed with the patient in prone position. For patients intolerant of prone positioning, ERCP in left lateral decubitus (LLD) position offers a potential alternative. Aims. To compare efficacy and safety of ERCP in the LLD position versus prone position. Methods. Consecutive ERCP reports from August 2009 to October 2010 at Mayo Clinic Arizona were reviewed. Inclusion criteria. Age > 18 years, native papilla, and biliary indication. Primary outcome measure. Bile duct cannulation rate. Secondary outcomes. Times to ampullary localization and bile duct cannulation and complication rate. Results. ERCPs reviewed from 59 patients in two positions: 39 prone and 20 LLD. Cannulation Rate. 100% prone versus 90% in LLD (P=0.11). Median (IRQ) times. (1) Ampullary localization: 90 sec (70–110) prone versus 100 sec (80–118) (P=0.16); (2) bile duct cannulation: 140 sec (45–350) prone versus 165 sec (55–418) LLD (P=0.54). Complications. No periprocedure; postprocedure 4 (10%) prone versus 3 (15%) LLD (P=0.65). Conclusion. ERCP performed in LLD position allowed deep bile duct cannulation in 90% of patients without significantly increased procedural times or rate of complications as compared to prone position.

Indications and Efficacy of Fiberoptic Bronchoscopy in the ICU: Have They Changed Since Its Introduction in Clinical Practice?

Purpose. We describe characteristics, utility, and safety of fiberoptic bronchoscopy (FOB) in an intensive care unit (ICU). Methods. Prospective and descriptive cohort of patients admitted to a respiratory ICU from March 2010 to June 2012. Results. A total of 102 FOBs were performed in 84 patients among 580 patients that were admitted to the ICU. Mean age was 48±17 years. FOB was useful in 65% of diagnostic procedures and 83% of therapeutic procedures, with an overall utility of 75%. Indications and utility according to indication were pneumonia in 31 cases, utility of 52%; percutaneous tracheostomy guidance in 26 cases, utility of 100%; atelectasis in 25 cases, utility of 76%; airway exploration in 16 cases, utility of 75%; hemoptysis in two cases, utility of 100%; and difficult airway intubation in two cases, utility of 100%. A decrease in oxygen saturation (SpO2) of >5% during FOB was present in 65% of cases, and other minor complications were present in 3.9% of cases. Conclusions. Reasons for performing FOB in the ICU have remained relatively stable over time with the exception of the addition of percutaneous tracheostomy guidance. Our series documents current indications and also the utility and safety of this procedure.

Expanded Endoscopic Endonasal Approach to Anterior and Ventral Skull Base: An Evolving Paradigm

The transition from external approaches to an endonasal corridor has seen a significant decline in patient morbidity and inpatient care. Our Rhinology and Cranial Base Surgery Group has been able to focus on the management of certain pathologies, endoscopic access to various areas in the skull base, reconstruction of the defect, ensuring that clear anatomical landmarks can be identified during the surgery, and improving the quality of life/function after treatment. The focus on surgical treatment is always to control disease and cure patients by not only reducing recovery time and perioperative morbidity, but also decreasing the long-term impact of having a tumour removed. With a dedicated combined operating theater setting with updated instrumentation, the Neuro-ENT team is able to continue to expand and develop endoscopic care for a greater number of patients and wider range of pathologies. The collaborative Neuro-ENT to work closely via the nose using the two-hole and four-hand technique when performing the operation simultaneously is of added advantage in the diverse and expanding field of cranial base surgery. Our skull base team is joined by expert radiation and medical oncologists who provide essential adjunctive care in the multidisciplinary management of these patients.

Diagnostic Yield of Routine Duodenal Biopsies in Iron Deficiency Anemia for Celiac Disease Diagnosis

Background. Iron deficiency anemia (IDA) is a recognised feature of celiac disease (CD) in adults and can be its only presentation. Aim. To define the prevalence of CD in Moroccan adult patients with IDA of obscure origin and to determine the yield of small bowel biopsy performed during routine endoscopy. Methods. 437 patients with IDA of obscure origin were included. 4 endoscopic mucosal biopsies were taken from the second part of duodenum and 2 biopsies from antrum and fundus, respectively. Endoscopic aspect and severity of anemia were correlated with histological diagnoses using coefficient Kappa. Results. 29 out of 437 patients (6.63%) had CD. Endoscopic aspect was normal in 66%, a mosaic pattern of mucosa in 17%, and scalloping of the small bowel folds in 17%. 12 patients had Marsh III, 8 had Marsh II, 6 had Marsh I, and 3 had Marsh IV lesions. There was no correlation between degree of anemia, endoscopic aspect, and severity of duodenal lesions . Conclusion. Routine duodenal biopsy gives an additional 6.63% diagnostic benefit of CD and should be indicated in all patients with IDA. The finding of normal endoscopic appearance of mucosa should not preclude duodenal biopsies.