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52 Part I Introduction
jaundice or cholangitis have a high risk of sepsis if adequate
drainage is not obtained. In addition, despite the use of sterile
contrast agents, ERCP is a contaminated procedure related to
the introduction of duodenal contents and bacteria into the
biliary tree during canulation. If contrast is injected above a
stricture that cannot be adequately drained, the development
of cholangitis uniformly occurs. One method for preventing
this is to attempt wire advancement across a stricture rst
before performing a cholangiogram. In complex strictures,
this can be challenging, but it avoids contamination in cases
where the stricture cannot be traversed. e performance of
biliary dilation also carries a very high risk of bacteremia and
prophylactic antibiotics are recommended. Finally, high pressure or high volume injections can also lead to cholangiovenous translocation of bacteria.
Bleeding following endoscopic sphincterotmy occurs in
approximately 1% of all cases, and can occur immediately
or up to 2 weeks postprocedure. Hemorrhage should be
initially managed by repeat endoscopic intervention. Injection sclerotherapy, balloon tamponade, and endoscopic
clip placement are the most common and eective ways to
94
manage this complication.
If unsuccessful, angiographic
embolization should be utilized before proceeding to surgical intervention.
Perforation is the least common complication and may
occur secondary to the ERCP intervention (wire placement, canulation, sphincterotomy) or the actual advancement of the endoscope. Endoscope-induced perforations
can occur at the level of the cervical esophagus due to the
blind nature of the initial passage of the side-viewing endoscope, or in the duodenum, usually on the lateral aspect
opposite the papilla. Proximal esophageal perforations usually can be managed with antibiotics, NPO status, and cervical drainage as needed. Duodenal perforations secondary
to the endoscope may result in a large rent of the lateral
wall and may require more aggressive therapy including
surgical drainage, or in more serious situations, duodenal
diversion techniques.
Perforations secondary to ERCP manipulations may
occur in the periampullary duodenum or in the biliary tree.
Perforations of the bile duct secondary to guide wires or
catheter systems are rare but can result in bile peritonitis.
Small perforations and leaks in patients without clinical
deterioration can usually be managed with transpapillary
stent placement and image-guided peritoneal drain placement as needed. CT scans are vital in the management of
95
these patients.
Microperforation of the duodenum can
lead to extensive retroperitneal, intraperitoneal, mediastinal, and subcutaneous air, which appears very concerning,
but as long as the patients are clinically stable, this situation
can routinely be managed conservatively with antibiotics,
NPO status, and close observation. Conversely, patients
identied to have retroperitoneal or intraperitoneal uid
collections will most likely require aggressive drainage via
either surgical or image-guided techniques. Emergent resective therapy (pancreaticoduodenectomy) should be avoided
in these situations.
SMALL BOWEL ENTEROSCOPY
e small bowel up until recently had been an elusive part of
the gastrointestinal tract in terms of diagnostic and therapeutic endoscopic intervention. e advent of capsule endoscopy
has permitted the endoscopist to obtain recorded images of
the lumen of the small bowel for identication of obscure
sites of bleeding, inammatory changes, and neoplasia.
Unlike contrast studies such as enteroclysis, capsule endoscopy simulated the visual advantages of exible endoscopy,
and with the time recording and navigation system, was able
to approximate the actual site of the identied disease. Unfortunately, there was no potential for tissue sampling or providing therapy. is deciency has now been addressed with the
progression of deep bowel enteroscopy.
Previous endoscopic approaches to evaluate the small
bowel included Sonde enteroscopy and push enteroscopy.
Both of these were very challenging, time consuming, often
unsuccessful, and provided limited alternatives for therapy.
Intraoperative enteroscopy, either transoral or transanal,
allowed for the manual pleating of the small bowel on the
enteroscope, but was also very challenging.
be provided surgically after the oending site was identied endoscopically. Intraoperative endoscopic evaluation of
the small bowel can also be performed via an enterotomy in
the midportion of the bowel allowing the endoscope to be
advanced both proximally and distally. One of the undesired
consequences of intraoperative endoscopy is massive bowel
distention. e use of CO
insuation rather than air insuf-
2
ation has been shown to minimize the overall distention and
length of time for resolution of this problem. Many endoscopists are looking to use CO
for all endoscopic interventions,
2
especially those that are expected to be of longer duration.
Over the past 10 years, several new endoscopic systems
have been developed and utilized for the evaluation and
treatment of small bowel disease. Double balloon endsocopy (DBE) and single balloon endoscopy (SBE) have
allowed the endoscopist to fully evaluate the small bowel,
obtain tissue samples, and provide therapy for processes
such as bleeding, obstruction, and occult neoplasia.
In addition, patients following surgical resection and
reconstruction (ie, Roux-en-Y bypass, long aerent limb),
balloon enteroscopy can allow access into the desired segment of the small bowel.
102
Both systems utilize the principle of scope xation with a
soft balloon that is serially inated and deated as the scope
is advanced. is permits the endoscopist to pleat the bowel
over the endoscope. is is perfomed both antegrade and retrograde to visualize the entire mucosal surface of the small
bowel, and can also be used for evaluation of the entire colon
following unsuccessful standard colonoscopy.
tubes are also available for deep bowel enteroscopy, and are
used in conjunction with the endoscopes.
niques can be somewhat time consuming (1–4 hours), it is
not uncommon to perform these under general anesthesia.
e use of uoroscopy is also helpful in guiding the endsocopist through the small bowel.
96
erapy would
104
Unique over-
101,103
As these tech-
97–105
Chapter 3 Endoscopy and Endoscopic Intervention 53
LOWER GASTROINTESTINAL
ENDOSCOPY
e eld of therapeutic lower endoscopy originated in 1975
when Shinya and Wol reported the rst series of colonoscopic
106
polypectomies.
is groundbreaking report transformed
colonoscopy from a purely diagnostic tool into an interventional
modality. Since then, therapeutic colonoscopy has expanded
to include resection of large neoplastic lesions, stenting for
management of leaks, strictures, stulae and obstructions, and
bleeding. Advances in instrumentation and technique will continue to broaden the applications of interventional colonoscopy,
possibly even using the colon as a portal to the peritoneal cavity.
Indications
Screening colonoscopy has become the standard of care for
evaluation of average risk patients over the age of 50.
Prior screening tools such as fecal occult blood testing, sigmoidoscoy, and digital rectal exams no longer are considered
111
as e ective screening tools.
CT colonography, however, has
gained some support due to improved abilities to identify
colonic neoplasia; however, smaller lesions are still somewhat
a challenge for this imaging tool. e indications for colonoscopy are listed in Table 3-3 .
107–110
comorbidities, underlying gastrointestinal disorders, or patient’s
inability to tolerate conscious sedation. As with EGD, recent
myocardial infarction, pneumonia, and recent foregut surgical
procedure are relative contraindications for colonoscopy, and
the risks and bene ts need to be weighed on an independent
basis for each patient to determine appropriateness. A recent
surgical anastomosis is most likely safe at any time during the
postoperative period to be evaluated endoscopically, remembering that tissue strength will be weakest on postoperative day’s
ve to seven.
Coagulopathy secondary to thrombocytopenia, liver
failure, renal failure, or exogenous use of anticoagulants
and platelet-inhibiting agents is a relative contraindication
for a diagnostic colonoscopy, but an absolute contraindication for a therapeutic intervention. Patient noncooperation or an inability for a patient to be safely sedated due
to high cardiopulmonary risk is also contraindication to
colonoscopy. Respiratory depression secondary to medications as well as inability to maintain an airway can occur in
these high-risk patients even though there is no transorally
placed scope. Preassessment with ASA classi cation and
Malampatti scores will help predict this high-risk group.
Patients with suspected perforation, ischemic colitis, acute
diverticulitis, or toxic megacolon should not undergo
colonoscopy unless there are plans to provide immediate
therapy such as endoscopic closure or stent placement, or
surgical intervention.
16
Contraindications
e contraindications for colonoscopy are in part similar
to those for EGD, and are related to the patient’s associated
TABLE 3-3: INDICATIONS FOR
COLONOSCOPY
Diagnostic
1. Evaluate and con rm radiographic ndings
2. Identify suspected polyps
3. Unexplained GI bleeding or iron de ciency anemia
4. Colon cancer screening and surveillance
5. Follow-up after intervention for polyp or cancer
6. Surveillance of in ammatory bowel disease
7. Signi cant unexplained diarrhea
8. Preoperative/intraoperative localization of lesions
Therapeutic
1. Control bleeding
2. Polypectomy
3. Remove foreign body
4. Reduce sigmoid volvulus
5. Decompress pseudo-obstruction (Ogilvie’s)
6. Dilate or stent strictures/stenoses (malignant and benign)
Adapted, with permission, from the Society of American Gastrointestinal and
Endoscopic Surgeons guidelines, www.colonoscopy.info , 2002; and the American
Society of Colon and Rectal Surgeons parameters, 2004.
Patient Preparation
Most endoscopic evaluations of the lower gastrointestinal tract
can be done under conscious sedation on an outpatient basis.
Unsedated colonoscopy can be performed safely but requires
a compliant, nonanxious patient, who understands that prior
abdominal surgery as well as female gender increases the need
for conversion to sedated endoscopy.
e day before the examination the patient should begin
a light diet with only clear liquids at lunch. e most common bowel preparation for colonoscopy utilizes a sodium
sulfate–based electrolyte solution containing polyethylene glycol as an osmotic agent (eg, GoLYTELY). Alternative regimens including magnesium citrate and multiple
enema solutions have also been described. In addition to
di erent agents for prep, endoscopists have also utilized
varied timing for preps with the use of split doses, with
the nal dose being given four hours before the scheduled
procedure. Fleet Phospho-soda, a small volume prep, is no
longer an alternative due to the rare occurrence of cardiac
complications.
Prophylactic antibiotics are usually not required for colonoscopy. Although diagnostic procedures can be performed in
patients on anticoagulative therapy, these medications should
be withdrawn if polypectomy or other therapeutic procedures
are expected to be performed. Aspirin therapy, unlike other
anticoagulative medications, probably does not alter the risk
of postpolypectomy bleeding.
54 Part I Introduction
Basic Endoscopic Techniques—
Colonoscopy
When performing colonoscopy, there are several universal
principles to the technique similar to upper endoscopy, but
there are also several specic caveats to assure performance of
a safe procedure. Due to the tortuosity of the colon and the
lack of xation, manipulations such as scope torquing, loop
reduction, patient position changes, and abdominal wall manual pressure are vital to the performance of colonoscopy. One
other dierence from upper endoscopy is the lack of reliability of correlation of shaft length inserted and actual anatomic
position in the colon. erefore, understanding specic colonoscopic landmarks is very important to interpreting actual
lower gastrointestinal anatomy. In addition, surgical alterations to the anatomy must be recognizable (Fig. 3-27).
A digital rectal examination should always be performed
prior to initiating the colonoscopic exam. is provides lubrication of the anal canal, relaxes the anal sphincters, provides
evaluation of the prostate and lower rectal vault, and assesses
the patient’s level of sedation. e endoscope is introduced
either by direct straight insertion or by rubbing the tip of
the endoscope along the perineal body with the right index
nger. Once reaching the anal verge, the tip of the endoscope
is directed into the anal canal.
Once in the rectal vault, insuation is initiated to allow
view of the lumen. Although mucosal inspection occurs during advancement, principal evaluation for pathology occurs
on scope withdrawal after the cecum is reached. Gentle
advancement of the colonoscope is now performed. If the
lumen is lost to view, termed a “red out,” the scope is slightly
pulled back and the wheels deected in combination with
scope torque to reestablish the lumen. Passage of the scope
FIGURE 3-27 An EEA stapled anastomosis at the rectosigmoid
level is seen in this image.
FIGURE 3-28 Multiple diverticuli seen in the sigmoid colon.
into the sigmoid colon can be challenging in patients with
prior abdominal surgery, morbid obesity and a large pannus,
or multiple diverticuli (Fig. 3-28). Abdominal compression
and patient position change to supine may assist in this
maneuver. Rarely, a “slide-by” maneuver is required to overcome the tight angulation in and out of the sigmoid colon.
is technique entails careful insertion without complete
luminal view but with appearance of the mucosa sliding by
the scope. During all portions of the colonoscopy, however,
increased patient discomfort, “redded out view,” and excessive scope resistance with advancement are markers to the
endoscopist to pull back one’s colonoscope.
Exiting the sigmoid colon may require building up a “loop.”
is may lead to increased patient discomfort and may require
additional medication. Once access into the descending colon
is achieved, the loop is reduced by gentle withdrawl and slight
torquing of the scope. Adding variable stiness to the scope,
if available, will now allow advancement in a one-to-one fashion, to the splenic exure. “One-to-one” refers to equal scope
tip advancement with scope insertion. e descending colon
is usually quite straight, and the splenic exure is identied
by the extraluminal blue hue as well as the tight turn encountered as one enters into the distal transverse colon. Suctioning
and scope withdrawal will assist in maintaining positioning
beyond the splenic exure.
Introduction of the scope, again with the addition of variable stiness, should allow one-to-one progress through the
transverse colon, which is easily identied by the triangular
conguration. As one proceeds toward the hepatic exure,
the blue hue of the liver becomes apparent. At this time, paradoxical motion routinely will occur with scope introduction.
Access into the ascending colon usually requires the endoscopist to make a sharp deection at the hepatic exure followed
by withdrawal of the scope and simultaneous suctioning.
e ascending colon may have a yellow discoloration due to
the continued passage of succus entericus despite a complete
bowel preparation. Asking the patient to take a deep breath
Chapter 3 Endoscopy and Endoscopic Intervention 55
FIGURE 3-29 e cecum is seen here, identied by the ileocecal
valve, appendiceal orice, and classic cecal strap.
FIGURE 3-31 Retroexed view in the rectal vault identifying the
dentate line and excluding any anorectal disease not able to be seen
on anteex view.
as well as placing them in supine position may assist in this
maneuver. Eventually, the cecum is identied by the ileocecal
valve, appendiceal orice, cecal strap, abdominal wall transillumination, and right lower quadrant palpation (Figs. 3-29
and 3-30). Intubation of the ileum, however, is the only way
to conrm 100% that you have actually reached the cecum.
e terminal ileum can be intubated by deecting the tip
toward the ileocecal valve, gently withdrawing the scope,
and prying open the upper lip of the valve. roughout this
maneuver, air insuation is used. e scope is then slowly
advanced into the terminal ileum.
e goal of the endoscopist is to reliably and safely gain
access into the cecum, conrming one’s position, and then
performing a slow careful withdrawal evaluating the entire
mucosal surface. Areas of excess stool must be ushed clear
and extra care must be taken at the exures and around
larger folds to investigate for underlying disease. Retroexion of the endoscope, which had been utilized for evaluation of the rectal vault, is now being performed with some
regularity, in the cecum and exures, as well as to see behind
larger folds. Manipulation by patient position change, as
with upper endoscpy, may aid in visualization of areas with
excess stool. Retroexion in the rectum can be done at the
beginning or at the end of the procedure (Fig. 3-31). e
colonoscope is withdrawn into the anal canal and then carefully advanced for several centimeters. Full upward deection along with clockwise torquing and gentle advancement
will result in the scope looking back toward the distal rectum
and dentate line.
FIGURE 3-30 Classic lipomatous appearance of the ileocecal valve
helps dierentiate it from other colonic folds.
Complications
Complications specically related to colonoscopy include
hemorrhage and perforation. e former is most unusual
following diagnostic colonoscopy, occurring in 0–0.07%
of cases. Hemorrhage in this setting is usually intraabdominal such as following injury to the colon mesentery
or to the capsule of the spleen, resulting from the use of
excessive force during manipulation. Hemorrhage is seen
more often following polypectomy (1–3%).
ectomy bleeding can be immediate or delayed, and can
occur up to 2 weeks after the procedure. Repeat colonoscopy is recommended for hemodynamic instability, transfusion requirement, and continued or recurrent episodes
of bleeding.
112
Postpolyp-
56 Part I Introduction
Perforation is the most common complication of colonos-
111
copy, occurring in <1% of cases.
ese injuries are caused
by mechanical or pneumatic pressure and are most common
at the rectosigmoid or sigmoid–descending colon junctions
along the antimesenteric border at the site of scope looping.
Alternatively, cecal perforation can occur if the colon is excessively insuated across a more distal nontraversable obstruction. In patients with a competent ileocecal valve, there is a
resultant trapping of air between the distal obstruction and
the valve, which prevents release of the insuated air into the
small bowel.
erapeutic colonoscopy can also be complicated by perforation, at the site of therapy, as well as the other previously
reported sites. Reported incidences are rare (<1%), with the
greatest risks occurring with the removal of sessile polyps.
Following polypectomy, patients occasionally develop localized pain secondary to peritoneal irritation, along with fever,
tachycardia, and leukocytosis. ere is usually no evidence of
diuse peritonitis or overt perforation (ie, no “free air”). is
syndrome has been labeled postpolypectomy syndrome, and is
probably attributable to a transmural electrocoagulation injury
with microperforation. Patients usually can be managed conservatively with antibiotics, analgesics, and close observation
with serial exams. Symptoms usually resolve within 48–72
hours and rarely are surgical interventions needed.
In patients with a suspected perforation, CT studies are
recommended to evaluate for abscess formation or intraabdominal uid collections. Intra-abdominal uid collection
is a more concerning nding and these patients require close
observation with a low tolerance for surgical intervention.
It is important to base therapy on individual patient status,
however, rather than just radiographic studies. e presence
of intraperitoneal or retroperitoneal air in the absence of clinical peritonitis or hemodynamic instability does not warrant
surgical exploration.
Polypectomy
By far, the most commonly performed colonoscopic intervention is polypectomy. When performed at regular intervals, removing adenomatous polyps has been shown to
signicantly reduce the incidence of colon cancer.
sessile lesions are amenable to hot or cold biopsy polypectomy. For hot polypectomy, standard biopsy forceps without
spike are attached to an electrocautery unit set at 10 to 20
watts. e polyp is grasped and lifted from the surrounding
mucosa, and monopolar cautery is applied in short bursts
until the base of the polyp whitens. e biopsy forceps is
sharply withdrawn and the polyp is then removed through
the working channel of the colonoscope. Polypectomy serves
to biopsy the polyp and ablate any residual tissue, thereby
diminishing the risk of progression to carcinoma. Due to
the concern for delayed bleeding following sloughing of the
eschar as well as the risk of perforation, many endoscopists
are now adopting cold polypectomy techniques. Several
series have shown no dierence in the rates of bleeding, and
107
Small
FIGURE 3-32 Small pedunculated polyp amenable to snare polyp-
ectomy technique.
it presents a more easily evaluable specimen to the pathologist without cautery artifact.
Pedunculated polyps are suitable for snare polypectomy
(Fig. 3-32). e base of the polyp is encircled with the snare
several millimeters below the head-stalk junction. is allows
removal of a portion of the stalk for pathologic evaluation to
rule out invasion of the lamina or muscular layers, identifying a more advanced neoplasm. Cautery is applied as the
snare is gradually closed, thus severing the polyp and cauterizing the base. Broader-based pedunculated polyps may be
managed with placement of an endoscopic pretied endoloop
proximal to the site of resection to help minimize bleeding.
ese loops usually will slough o within several weeks and
pass spontaneously.
Sessile polyps are frequently more dicult to manage
than pedunculated polyps. Small sessile lesions may be captured in a single application of a snare and resected, with
(hot) or without (cold) cautery, while larger lesions might
require resection in a piecemeal fashion. Piecemeal resection
provides for removal of a larger lesion along with ablation
of residual tissue, but may make pathologic interpretation
more challenging.
113
Resection of sessile polyps poses a higher risk of colonic
perforation than pedunculated polyps. Given that, endoscopic mucosal resection has been developed to minimize
the risk of perforation and ensure complete resection of the
lesion. is is provided by submucosal injection of saline to
create a cushion between the mucosa and muscularis, to help
113–116
minimize the risk for perforation.
Lesions that do not
easily elevate may have a component of invasisve carcinoma
and these tumors should be biopsied and tattooed, rather
than attempted to be endoscopically resected. Following
removal of large sessile lesions, APC ablation of the site has
been proposed to minimize adenoma recurrence.
Chapter 3 Endoscopy and Endoscopic Intervention 57
POLYP RETRIEVAL
Small polyps may be retrieved through the suction channel of
the endoscope and captured in a trap. Larger polyps may be
recovered in a net placed through the working channel of the
endoscope or apposed to the tip of the endoscope by constant
application of suction and then withdrawn with the scope.
Marking the site of resection with a carbon particle–based
tattoo via a sclerotherapy needle will allow for more accurate
surveillance, as well as to guide surgery if the polyp proves to
be malignant. Injections should be placed at multiple sites
circumferentially to allow for the most reliable visualization at the time of surgery or during subsequent surveillance
endoscopy.
POLYP SURVEILLANCE
Over the past 15 years, much has been learned about the
nature of the adenoma carcinoma sequence, leading to ongoing changes in the recommendations for polyp surveillance.
Average risk patients with satisfactory bowel preps require
repeat surveillance in 10 years, while patients with those with
poorer preps might be recommened to have a shorter interval
of 5 to 7 years.
107,109–111
Hyperplastic polyps carry an undetermined risk/association with advanced neoplasia, although
there has been some suggestion that left-side hyperplastic
lesions have a more aggressive nature than those in the rectosigmoid. Similar to fundic gland polyps of the stomach, these
lesions may be sampled but do not need to be fully removed.
Tubular adenomas, tubulovillous adenomas, and villous adenomas warrant a surveillance colonoscopy at 5, 3, and 1 year,
respectively.
107
Colonoscopic therapy for lower gastrointestinal hemorrhage within 6 to 24 hours of admission has been shown
to diminish rates of rebleeding and reduce the necessity
117
for urgent surgical intervention.
Various methods are
available for hemostasis including thermal and nonthermal devices, and are described in the preceding sections of
this chapter. One must always remember, however, that the
colon wall is thinner, especially on the right side, as compared to the stomach. Depth of penetration of the varied
thermal endoscopic devices must be closely considered to
avoid full thickness perforations.
Diverticular disease is the most frequent cause of lower
gastrointestinal hemorrhage. Up to 75% of diverticular bleeds
are self-limited, but in those patients with transfusion requirements, massive hematochezia, or hemodynamic instability,
colonoscopy may aid in conrming diagnosis, identifying
the site, achieving hemostasis and limiting patient morbid-
117–121
ity.
Locating the precise site of bleeding may be dicult
in the face of multiple diverticula and a blood-stained colon.
e bleeding diverticular vessel is frequently at the lip of the
diverticulum, although bleeding vessels in the dome of the
diverticulum may also occur. e use of endoscopic clips and
ligation bands for treatment of bleeding diverticuli has also
been reported.
120,121
Vascular ectasia or angiodyspoasia, commonly in the right
colon but also routinely multicentric, is another common
cause of lower gastrointestinal hemorrhage. Argon plasma
coagulation is invaluable in this situation, but care should
be taken to avoid excessive distension of the bowel, as the
122
argon gas accumulates and could lead to perforation.
Other
thermal endoscopic contact probes, as described in previous
sections of this chapter, can also be utilized.
Lower Gastrointestinal Bleeding
Sources of lower gastrointestinal bleeding include UGI bleeding,
infection, ischemia, neoplasia, diverticulosis, angiodysplasia,
and anorectal disease. A detailed history of the nature of
bleeding is vital to the management of patients with lower
gastrointestinal bleeding identifying underlying coagulopathy, recent surgical or colonoscopic interventions (polypectomy), and associated comorbid diseases. ese factors are
important in patient management and guiding surgical and
nonsurgical interventions.
e role of bowel preparation prior to colonoscopy in the
face of lower gastrointestinal bleeding is dependent on the
rapidity of the bleeding. As blood is a very active cathartic,
colonoscopy can be performed in the unprepped colon with
extensive bleeding.
hours can be utilized in patients with less aggressive bleeding prior to endoscopic evaluation. e endoscopist must
compare the need for a more urgent intervention versus the
necessity of a more adequately cleared mucosal surface. In
addition, newer irrigation devices are now available that can
be axed to the colonoscope to provide for high pressue
and volume irrigation and cleaning.
117–119
Otherwise, a rapid prep over 3 to 4
Colonoscopic Decompression
Mechanical or nonmechanical obstructions with unrelieved
distention of the colon, in addition to leading to patient
discomfort, can result in bowel ischemia, perforation, and
death. In patients with colonic distention secondary to acute
pseudo-obstruction, Ogilvie’s syndrome, colonoscopy provides both a diagnostic and therapeutic potential. Underlying
etiologies including ischemia, infectious colitis, or an unsuspected obstructing lesion must be excluded.
Conservative treatment is initially indicated in patients
with benign abdominal exams, clinical stability, and cecal
diameters less than 12 cm. Patients should be maintained
NPO, electrolyte imbalances corrected, narcotics withdrawn,
and one should consider possible placement of nasogastric
and rectal tubes.
Colonoscopic decompression is done without a routine
bowel preparation, thus limiting the overall mucosal evaluation. e endoscope is advanced, with limited air insuation,
as far proximally as can be achieved without excessive bowel
wall tension, minimizing any risk for perforation. Decompression is then performed upon withdrawal of the colonoscope,
suctioning both uid and intraluminal air. Although the cecum
58 Part I Introduction
FIGURE 3-33 An obstructing sigmoid colon cancer prior to stent
placement.
is the optimal endpoint, successful decompression can also be
achieved with a less complete colonoscopy. Evaluation of visualized segments of the colon for ischemia and/or mechanical
obstruction, possibly requiring stent placement or dilation, is
crucial. It must be understood that repeat colonoscopic decompression is routinely required in patients with pseudo-obstruction, and they should be watched closely for several days.
Enteral Stents
Colonic stenting can provide relief of malignant colon
obstruction or benign stricture and serve either as palliation or as a bridge to operation.
123–127
Permanent SEMT are
FIGURE 3-35 Following stent deployment, obstruction is relieved
as seen by the large volume of liquid stool.
commonly employed in large bowel obstruction. roughthe-scope stents are placed under endoscopic and uoroscopic guidance. e malignant stricture is located endoscopically and a guide wire is passed through the narrowed
lumen (Figs. 3-33 and 3-34). Contrast is injected into
the bowel lumen, typically through an ERCP catheter, to
dene the borders of the stricture. If possible, the proximal and distal extents of the stricture are marked by injecting submucosal contrast. e stent is then placed over the
wire, positioned properly, and deployed (Fig. 3-35). Selfexpanding metal stents have shown ecacy in reducing the
need for emergency operation in acute large bowel obstruc-
123,124,126
tion.
tion, metal stents may serve a palliative purpose.
In patients who are not candidates for opera-
125
Stenting
is generally safe, although perforation has been reported
in up to 10% of cases. Migration of stents can also occur,
although is less likely due to tissue in-growth, which can
also lead to subsequent stent occlusion.
FIGURE 3-34 Guide wire placement across the obstructing lesion.
ENDOSCOPIC ULTRASOUND
Endoscopic ultrasound has become a mainstay in the diagnostic and therapeutic armamentarium of endoscopy (Table
3-4). e staging of neoplastic processes throughout the
gastrointestinal tract, and those structures adjacent to the
hollow viscera, can now be more accurately accomplished,
with the addition of tissue sampling for conrmation of
disease.
closely tied to the results of endoscopic ultrasonographic
ndings, providing for more appropriate patient care.
Finally, directed therapy for endoscopic removal, drainage,
and palliation of gastrointestinal and extragastrointestinal
diseases is now readily being performed with the assistance
of EUS.
128–130
e use of neoadjuvant therapy has become
131
Chapter 3 Endoscopy and Endoscopic Intervention 59
TABLE 3-4: INDICATIONS FOR
ENDOSCOPIC ULTRASOUND
Pancreatic
1. Fine-needle aspiration and cytology of cystic or solid lesions
2. Drainage of uid collections
3. Lymph node sampling (to determine resectability)
4. Assess portal venous system
5. Intraductal ultrasound
6. Ampullary mass
Hepatobiliary
1. Detect stones (in conjunction with or in lieu of ERCP)
2. Intraductal ultrasound
3. Periportal lymph node sampling
4. Biopsy of liver mass
Mediastinal
1. Aortopulmonary window lymph node sampling (in lieu of
mediastinoscopy)
2. Bronchial and carinal tissue sampling/cytology
3. Lung cancer staging
Esophageal
1. Esophageal cancer staging
2. Follow-up of hiatal hernia repair and antire ux surgery (under
investigation)
Gastric
1. Gastric cancer staging
2. Evaluation of submucosal masses
Retroperitoneal
1. Lymph node cytology
2. Celiac axis nerve blocks
3. Retroperitoneal biopsies
4. Renal/adrenal biopsies
Colorectal
1. Anorectal cancer staging
2. Anorectal lymph node evaluation
3. Anal sphincter evaluation
4. Perirectal abscess detection and management
FUTURE DEVELOPMENTS
e future developments in endoscopy will be based on
advancements of both the tools and the applications available to endoluminal therapy. As surgery becomes less invasive
with the advancement of laparoscopy, endoscopy is taking
on an increasingly more invasive and therapeutic role. Intraluminal and translumenal procedures are being developed
with the goal of further supplanting surgery. Recent interest
in NOTES united surgeons and gastroenterologists with the
desire to access the abdominal cavity via naturally existing
ori ces including the stomach, colon, bladder, and vagina.
Using existing endoscopic technology, investigators have
attempted numerous intra-abdominal procedures in porcine
models, and eventually human cases under laparoscopic guidance have also been reported.
for this approach is still yet to be elucidated. It is theorized
that NOTES may have distinct advantages over laparoscopy in that it may not necessarily require a sterile working
environment to perform, and it possibly could also be completed under conscious sedation similar to other endoscopic
134,
135
procedures.
e obvious limitations to NOTES were based on the
lack of adequate and appropriate endoscopic equipment.
e accessories were too imsy to perform intra-abdominal
manipulation of tissue, and the endoscopes were too exible,
inhibiting access and stable positioning once in the abdominal cavity. It was apparent early on that stable platforms
would be necessary as well as endoscopic tools for cutting,
hemostasis, and tissue manipulation. Transoral and transvaginal multichannel platforms with internal capability for
manipulation and xation are now becoming available. Scissors, suturing devices, bipolar forceps, and grasping devices
are a few of the novel instruments soon to be added to the
endoscopist’s armamentarium.
ese tools, however, will have a more likely impact on
intraluminal endoscopic surgery.
thickness resection, intraluminal anastomoses, and closure of
perforations are all likely procedures to be seen in the very
near future, and it is imperative that surgeons stay abreast of
the numerous advancements in these technologies.
132,
133
An appropriate application
136
e ability to perform full
e echoscope endoscopically visualizes similar to a sideviewing duodenoscope. After providing appropriate sedation,
endoscopic visualization is used initially to achieve appropriate scope position. Once the endoscope is in the desired
position, a balloon on the endoscope tip is lled with deaerated water. e lumen of the GI tract is suctioned to a x
the scope adjacent to the mucosal surface as excess air limits
ultrasound views. Miniature probes as well as Doppler capabilities are also available. When a lesion is found, the working
port of the scope allows for passage of a 19 or 20 gauge needle
to obtain ne-needle aspiration biopsies. Immediate cytologic evaluation is recommended as repeat passes for further
samples is commonly required.
REFERENCES
1. Sivak MV. Gastrointestinal endoscopy: past and future. Gut.
2006;55(8):1061–1064.
2. Ponsky JL. Endoluminal surgery: past, present and future. Surg Endosc.
2006;20(Suppl 2):S500–S502.
3. Chiu HM, Chang CY, Chen CC, et al. A prospective comparative study
of narrowband imaging, chromoendoscopy, and conventional colonoscopy in the diagnosis of colorectal neoplasia. Gut. 2007;56(3):373–379.
4. Pearl JP, Marks JM. New t echnology in endoscopy. In: Soper NJ, ed.
Mastery of Endoscopic and Laparoscopic Surgery . 2nd ed. Lippincott
Willians & Wilkins: Philadelphia, PA; 2009:17–23.
5. Tischendorf JJ, Schirin-Sokhan R, Streetz K, et al. Value of magnifying
endoscopy in classifying colorectal polyps based on vascular pattern.
Endoscopy . 2009 Nov 6. [Epub ahead of print].
6. Kawahara Y, Takenaka R, Okada H, et al. Novel chromoendoscopic
method using an acetic acid-indigocarmine mixture for diagnostic
60 Part I Introduction
accuracy in delineating the margin of early gastric cancers. Dig Endosc.
2009 Jan;21(1):14–19.
7. Ignjatovic A, East JE, Suzuki N, et al. Optical diagnosis of small colorectal polyps at routine colonoscopy (Detect InSpect ChAracterise Resect
and Discard; DISCARD trial): a prospective cohort study. Lancet Oncol.
2009 Nov 10. [Epub ahead of print].
8. Mannath J, Ragunath K. Dig Narrow band imaging and high resolution endoscopy with magnication could be useful in identifying gastric
atrophy. Dis Sci. 2009 Oct 3. [Epub ahead of print].
9. Kato M, Kaise M, Yonezawa J, et al. Trimodal imaging endoscopy may
improve diagnostic accuracy of early gastric neoplasia: a feasibility study.
Gastrointest Endosc. 2009 Nov;70(5):899–906.
10. Isenberg G, Sivak MV Jr, Chak A, et al. Accuracy of endoscopic
optical coherence tomography in the detection of dysplasia in Barrett’s
esophagus: a prospective, doubleblinded study. Gastrointest Endosc.
2005;62(6):825–831.
11. Othman MO, Bradley AG, Choudhary A, et al. Variable stiness colonoscope versus regular adult colonoscope: meta-analysis of randomized
controlled trials. Endoscopy. 2009 Jan;41(1):17–24
12. Lee DW, Li AC, Ko CW, et al. Use of a variable-stiness colonoscope
decreases the dose of patient-controlled sedation during colonoscopy:
a randomized comparison of 3 colonoscopes. Gastrointest Endosc. 2007
Mar;65(3):424–429.
13. Hawari R, Pasricha PJ. Going for the loop: a unique overtube for the
dicult colonoscopy. J Clin Gastroenterol. 2007 Feb;41(2):138–140.
14. Bittner JG, Marks JM, Dunkin BJ, et al. Resident training in exible
gastrointestinal endoscopy: a review of current issues and options. J Surg
Edu. 2007;10:399–403.
15. Pearl J, Marks J. e future of teaching surgical endoscopy. Surg Innov.
2006;13(4):280–282.
16. Dunkin BJ. Flexible endoscopy simulators. Semin Laparosc Surg.
2003;10:29–35.
17. Qadeer MA, Rocio Lopez A, Dumot JA, et al. Risk factors for hypoxemia
during ambulatory gastrointestinal endoscopy in ASA I-II patients. Dig
Dis Sci. 2009 May;54(5):1035–1040.
18. Khiani VS, Salah W, Maimone S, et al. Sedation during endoscopy for
patients at risk of obstructive sleep apnea. Gastrointest Endosc. 2009 Aug
4. [Epub ahead of print].
19. Waring JP, Baron TH, Hirota WK, et al; the American Society for
Gastrointestinal Endoscopy, Standards of Practice Committee. Guidelines
for conscious sedation and monitoring during gastrointestinal endoscopy.
Gastrointest Endosc. 2003;58:317–322.
20. Faigel DO, Baron TH, Goldstein JL et al; the Standards of Practice Committee, American Society for Gastrointestinal Endoscopy.
Guidelines for the use of deep sedation and anesthesia for GI endoscopy.
Gastrointest Endosc. 2002;56:613–617.
21. VanNatta ME, Rex DK. Propofol alone titrated to deep sedation versus
propofol in combination with opioids and/or benzodiazepines and
titrated to moderate sedation for colonoscopy. Am J Gastroenterol. 2006
Oct;101(10):2209–2217.
22. Adler DG, Leighton JA, Davila RE et al; the American Society for
Gastrointestinal Endoscopy. ASGE guideline: the role of endoscopy in acute non-variceal upper-GI hemorrhage. Gastrointest Endosc.
2004;60:497–504.
23. Cappell MS, Friedel D. Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy. Med Clin North Am. 2008
May;92(3):511–550.
24. Tang SJ, Lee SY, Hynan LS, et al. Endoscopic hemostasis in nonvariceal
upper gastrointestinal bleeding: comparison of physician practice in the
east and the west. Dig Dis Sci. 2009 Nov;54(11):2418–2426.
25. Zepeda-Gómez S, Marcon NE. Endoscopic band ligation for nonvariceal bleeding: a review.Can J Gastroenterol. 2008 Sep;22(9):748–752.
26. Guo SB, Gong AX, Leng J, et al. Application of endoscopic hemoclips
for nonvariceal bleeding in the upper gastrointestinal tract. World J
Gastroenterol. 2009 Sep 14;15(34):4322–4326.
27. Kapetanos D, Beltsis A, Chatzimavroudis G, et al. e use of endoclips
in the treatment of nonvariceal gastrointestinal bleeding. Surg Laparosc
Endosc Percutan Tech. 2009 Feb;19(1):2–10.
28. Yuan Y, Wang C, Hunt RH. Endoscopic clipping for acute nonvariceal
upper-GI bleeding: a meta-analysis and critical appraisal of randomized
controlled trials. Gastrointest Endosc. 2008 Aug;68(2):339–351.
29. Chennat J, Konda VJ, Ross AS, et al. Complete Barrett’s eradication
endoscopic mucosal resection: an eective treatment modality for high-
grade dysplasia and intramucosal carcinoma—an American single-center
experience. Am J Gastroenterol. 2009 Nov;104(11):2684–2692.
30. Avilés A, Reymunde A, Santiago N. Balloon-based electrode for the ablation of non-dysplastic Barrett’s esophagus: ablation of intestinal metaplasia (AIM II Trial). Bol Asoc Med P R. 2006 Oct–Dec;98(4):270–275.
31. Ganz RA, Overholt BF, Sharma VK, et al. Circumferential ablation of
Barrett’s esophagus that contains high-grade dysplasia: a U.S. Multicenter Registry. Gastrointest Endosc. 2008 Jul;68(1):35–40.
32. Fleischer DE, Overholt BF, Sharma VK, et al. Endoscopic ablation of
Barrett’s esophagus: a multicenter study with 2.5-year follow-up. Gastro-
intest Endosc. 2008 Nov;68(5):867–876.
33. Sharma VK, Kim HJ, Das A, et al. A prospective pilot trial of ablation of Barrett’s esophagus with low-grade dysplasia using stepwise
circumferential and focal ablation (HALO system). Endoscopy. 2008
May;40(5):380–387.
34. Panagiotakis PH, DiSario JA, Hilden K, et al. DPEJ tube placement prevents aspiration pneumonia in high-risk patients. Nutr Clin Pract. 2008
Apr–May;23(2):172–175.
35. Freeman C, Delegge MH. Small bowel endoscopic enteral access. Curr
Opin Gastroenterol. 2009 Mar;25(2):155–159.
36. Virnig DJ, Frech EJ, Delegge MH, et al. Direct percutaneous endoscopic
jejunostomy: a case series in pediatric patients.Gastrointest Endosc. 2008
May;67(6):984–987.
37. Del Piano M, Ballarè M, Carmagnola S, et al. DPEJ placement in cases
of PEG insertion failure. Dig Liver Dis. 2008 Feb;40(2):140–143.
38. DeLegge MH. Small bowel endoscopic enteral access. Gastrointest Endosc
Clin N Am. 2007 Oct;17(4):663–686.
39. American Society for Gastrointestinal Endoscopy. Guideline for the
management of ingested foreign bodies. Gastrointest Endosc. 1995;
42:622–625.
40. Palta R, Sahota A, Bemarki A, et al. Foreign-body ingestion: characteristics and outcomes in a lower socioeconomic population with predominantly intentional ingestion Gastrointest Endosc. 2009 Mar;69(3 Pt 1):
426–433.
41. Prasad GA, Reddy JG, Boyd-Enders FT, et al. Predictors of recurrent
esophageal food impaction: a case-control study. J Clin Gastroenterol.
2008 Aug;42(7):771–775.
42. American Society for Gastrointestinal Endoscopy Guideline. Esophageal
dilation. Gastrointest Endosc. 1998;48:702–704.
43. Keränen I, Udd M, Lepistö A, et al. Outcome for self-expandable metal
stents in malignant gastroduodenal obstruction: single-center experience
with 104 patients. Surg Endosc. 2009 Sep 3. [Epub ahead of print].
44. Moon JH, Choi HJ, Ko BM, et al. Combined endoscopic stent- in-stent
placement for malignant biliary and duodenal obstruction by using a
new duodenal metal stent (with videos). Gastrointest Endosc. 2009 Oct;
70(4):772–777.
45. Babor R, Talbot M, Tyndal A. Treatment of upper gastrointestinal leaks
with a removable, covered, self-expanding metallic stent. Surg Laparosc
Endosc Percutan Tech. 2009 Feb;19(1):e1–e4.
46. van Hooft JE, Uitdehaag MJ, Bruno MJ, et al. Ecacy and safety of the
new WallFlex enteral stent in palliative treatment of malignant gastric
outlet obstruction (DUOFLEX study): a prospective multicenter study.
Gastrointest Endosc. 2009 May;69(6):1059–1066.
47. Phillips MS, Gosain S, Bonatti H, et al. Enteral stents for malignancy:
a report of 46 consecutive cases over 10 years, with critical review of
complications. J Gastrointest Surg. 2008 Nov;12(11):2045–2050.
48. Huang Q, Dai DK, Qian XJ, et al. Treatment of gastric outlet and
duodenal obstructions with uncovered expandable metal stents. World J
Gastroenterol. 2007 Oct 28;13(40):5376–5379.
49. Gupta K, Freeman ML. Enteral and colonic self-expanding metallic
stents. Rev Gastroenterol Disord. 2008 Spring;8(2):83–97.
50. Small AJ, Young-Fadok TM, Baron TH. Expandable metal stent
placement for benign colorectal obstruction: outcomes for 23 cases. Surg
Endosc. 2008 Feb;22(2):454–462.
51. Schiefke I, Zabel-Langhennig A, Neumann S, et al. Long term failure of
endoscopic gastroplication (EndoCinch). Gut. 2005 Jun;54(6):752–758.
52. Abou-Rebyeh H, Hoepner N, Rosch T, et al. Long-term failure of
endoscopic suturing in the treatment of gastroesophageal reux: a
prospective follow-up study. Endoscopy. 2005 Mar;37(3):213–216.
53. Pearl J, Marks J. Endolumenal therapies for gastroesophageal reux
disease: are they dead? Surg Endosc. 2007;21(1):1–4.
54. Lut RE, Torquati A, Richards WO. Endoscopic treatment modalities
for gastroesophageal reux disease. Surg Endosc. 2004;18:1299–1315.
Chapter 3 Endoscopy and Endoscopic Intervention 61
55. Lut RE, Torquati A, Kaiser J, et al. ree year’s experience with the
Stretta procedure: did it really make a dierence? Surg Endosc. 2005
Feb;19(2):289–295.
56. Wolfsen HC, Richards WO. e Stretta procedure for the treatment of
GERD: a registry of 558 patients. J Laparoendosc Adv Surg Tech A. 2002
Dec;12(6):395–402.
57. Triadalopoulos G, DiBaise JK, Nostrant TT, et al. e Stretta procedure for the treatment of GERD: 6 and 12 month follow-up of the U.S.
open label trial. Gastrointest Endosc. 2002 Feb;55(2):149–156.
58. Chuttani R, Sud R, Sachdev G, et al. A novel endoscopic full-thickness
plicator for the treatment of GERD: a pilot study. Gastrointest Endosc.
2003 Nov;58(5):770–776.
59. Haber G, Sakai P, Moura E, Maluf-Filho F, Pleskow D, Lembo A. e
Plicator procedure for the treatment of GERD: 12-month multicenter
results. Gastrointest Endosc. 2005;61:5.
60. Lin E, Smith CD, Sedghi S. Objective improvements following full
thickness gastric cardia plication for complicated GERD. SAGES. 2005.
61. Pleskow D, Rothstein R, Lo S, et al. Endoscopic full-thickness placation
for the treatment of GERD: 12-month follow-up for the North American
open-label trial. Gastrointest Endosc. 2005;61:6,643–649.
62. Deviere J, Costamagna G, Neuhaus H, et al. Nonresorbable copolymer
implantation for gastroesophageal reux disease: a randomized shamcontrolled multicenter trial. Gastroenterology. 2005 Mar;128(3):532–540.
63. Schumacher B, Neuhaus H, Ortner M, et al. Reduced medication
dependency and improved symptoms and quality of life 12 months after
enteryx implantation for gastroesophageal reux. J Clin Gastroenterol.
2005 Mar;39(3):212–219.
64. Cohen LB, Johnson DA, Ganz RA, et al. Enteryx implantation for
GERD: expanded multicenter trial results and interim postapproval
follow-up to 24 months. Gastrointest Endosc. 2005 May;61(6):
650–658.
65. Noh KW, Loeb DS, Stockland A, et al. Pneumomediastinum following
Enteryx injection for the treatment of gastroesophageal reux disease.
Am J Gastroenterol. 2005 Mar;100(3):723–726.
66. Tintillier M, Chaput A, Kirch L, et al. Esophageal abscess complicating endoscopic treatment of refractory gastroesophageal reux disease
by Enteryx injection: a rst case report. Am J Gastroenterol. 2004 Sep;
99(9):1856–1858.
67. Wong RF, Davis TV, Peterson KA. Complications involving the mediastinum after injection of Enteryx for GERD. Gastrointest Endosc. 2005
May;61(6):753–756.
68. FDA preliminary public health notication: recall of Boston Scientic
Enteryx procedure kits and Enteryx injector single packs for treatment
of gastroesophageal reux disease (GERD). http://www.fda.gov/cdrh/
safety/101405-enteryx.html. Accessed November 15, 2009.
69. Cicala M, Gabbrielli A, Emerenziani S, et al. Eect of endoscopic augmentation of the lower oesophageal sphincter (Gatekeeper reux repair
system) on intraoesophageal dynamic characteristics of acid reux. Gut.
2005 Feb;54(2):183–186.
70. Fockens P, Bruno MJ, Gabbrielli A, et al. Endoscopic augmentation of
the lower esophageal sphincter for the treatment of gastroesophageal
reux disease: multicenter study of the Gatekeeper Reux Repair System.
Endoscopy. 2004 Aug;36(8):682–689.
71. Adler DG, Baron TH, Davila RE et al; the Standards of Practice
Committee of the American Society for Gastrointestinal Endoscopy.
ASGE guideline: the role of ERCP in diseases of the biliary tract and the
pancreas. Gastrointest Endosc. 2005;62:1–8.
72. Scadi MG, Luigiano C, Consolo P, et al. Magnetic resonance
cholangio-pancreatography versus endoscopic retrograde cholangiopancreatography in the diagnosis of common bile duct stones: a prospective
comparative study. Minerva Med. 2009 Oct;100(5):341–348.
73. Parra-Membrives P, Díaz-Gómez D, Vilegas-Portero R, et al. Appropriate management of common bile duct stones: a RAND Corporation/
UCLA Appropriateness Method statistical analysis. Surg Endosc. 2009
Nov 14. [Epub ahead of print].
74. Folkers MT, Disario JA, Adler DG. Long-term complications of endoscopic
biliary sphincterotomy for choledocholithiasis: a North-American perspective. Am J Gastroenterol. 2009 Nov;104(11):2868–2869.
75. Madácsy L, Kurucsai G, Fejes R, et al. Prophylactic pancreas stenting
followed by needle-knife stulotomy in patients with sphincter of Oddi
dysfunction and dicult cannulation: new method to prevent post-ERCP pancreatitis. Dig Endosc. 2009 Jan;21(1):8–13.
76. Sherman S. What is the role of ERCP in the setting of abdominal pain
of pancreatic or biliary origin (suspected sphincter of Oddi dysfunction)?
Gastrointest Endosc. 2002 Dec;56(6 Suppl):S258–S266.
77. Horakova M, Vadovicova I, Katuscak I, et al. Consideration of endoscopic
retrograde cholangiopancreatography in cases of acute biliary pancreatitis.
Bratisl Lek Listy. 2009;110(9):553–558.
78. Uy MC, Daez ML, Sy PP, et al. Early ERCP in acute gallstone
pancreatitis without cholangitis: a meta-analysis. JOP. 2009 May
18;10(3):299–305.
79. Nguyen-Tang T, Frossard JL, Dumonceau JM. Endoscopic management
of benign biliary strictures. Rev Med Suisse. 2009 Sep 2;5(215):1714–1716,
1718–1719.
80. Perdue DG, Freeman ML, DiSario JA, et al. Plastic versus self-expanding
metallic stents for malignant hilar biliary obstruction: a prospective
multicenter observational cohort study. J Clin Gastroenterol. 2008
Oct;42(9):1040–1046.
81. Wasan SM, Ross WA, Staerkel GA, et al. Use of expandable metallic
biliary stents in resectable pancreatic cancer. Am J Gastroenterol. 2005
Sep;100(9):2056–2061.
82. Piñol V, Castells A, Bordas JM, et al. Percutaneous self-expanding
metal stents versus endoscopic polyethylene endoprostheses for treating
malignant biliary obstruction: randomized clinical trial. Radiology. 2002
Oct;225(1):27–34.
83. Baillie J. Endoscopic therapy in acute recurrent pancreatitis. World J
Gastroenterol. 2008 Feb 21;14(7):1034–1037.
84. Lerch MM, Stier A, Wahnschae U, et al. Pancreatic pseudocysts:
observation, endoscopic drainage, or resection? Dtsch Arztebl Int. 2009
Sep;106(38):614–621.
85. Park DH, Lee SS, Moon SH, et al. Endoscopic ultrasound-guided versus
conventional transmural drainage for pancreatic pseudocysts: a prospective randomized trial. Endoscopy. 2009 Oct;41(10):842–848.
86. Bhasin DK, Rana SS, Nanda M, et al. Endoscopic management of
pancreatic pseudocysts at atypical locations. Surg Endosc. 2009 Nov 14.
[Epub ahead of print].
87. Yasuda I, Iwata K, Mukai T, et al. Eus-guided pancreatic pseudocyst
drainage. Dig Endosc. 2009 Jul;21(Suppl 1):S82–S86.
88. Ang TL, Teo EK, Fock KM. Endoscopic drainage and endoscopic necrosectomy in the management of symptomatic pancreatic collections. J Dig Dis.
2009 Aug;10(3):213–224.
89. Babu BI, Siriwardena AK. Current status of minimally invasive necrosectomy for post-inammatory pancreatic necrosis. HPB. 2009;11(2):
96–102.
90. Talreja JP, Kahaleh M. Endotherapy for pancreatic necrosis and abscess:
endoscopic drainage and necrosectomy. J Hepatobiliary Pancreat Surg.
2009;16(5):605–612.
91. Friedland S, Kaltenbach T, Sugimoto M, et al. Endoscopic necrosectomy
of organized pancreatic necrosis: a currently practiced NOTES procedure. J Hepatobiliary Pancreat Surg. 2009;16(3):266–269.
92. Seifert H, Biermer M, Schmitt W, et al. Transluminal endoscopic
necrosectomy after acute pancreatitis: a multicentre study with longterm follow-up (the GEPARD Study). Gut. 2009 Sep;58(9):1260–1266.
93. Cotton PB, Garrow DA, Gallagher J, et al. Risk factors for complications
after ERCP: a multivariate analysis of 11,497 procedures over 12 years.
Gastrointest Endosc. 2009 Jul;70(1):80–88.
94. Tsou YK, Lin CH, Liu NJ, et al. Treating delayed endoscopic sphincterotomy-induced bleeding: epinephrine injection with or without thermotherapy. World J Gastroenterol. 2009 Oct 14;15(38):4823–4828.
95. Morgan KA, Fontenot BB, Ruddy JM, et al. Endoscopic retrograde cholangiopancreatography gut perforations: when to wait! When to operate!
Am Surg. 2009 Jun;75(6):477–483; discussion 483–484.
96. Moreels TG. History of endoscopic devices for the exploration of the
small bowel. Acta Gastroenterol Belg. 2009 Jul–Sep;72(3):335–337.
97. Monkemuller K, Weigt J, Treiber G, et al. Diagnostic and therapeutic
impact of double balloon enteroscopy. Endoscopy. 2006;38(1):67–72.
98. Lahat A, Nadler M, Simon C, et al. Double balloon enteroscopy: a 2 year
experience. Isr Med Assoc J. 2009 Aug;11(8):456–459.
99. Moreels TG, Hubens GJ, Ysebaert DK, et al. Diagnostic and therapeutic
double-balloon enteroscopy after small bowel Roux-en-Y reconstructive
surgery. Digestion. 2009;80(3):141–147.
100. Rondonotti E, Villa F, Saladino V, et al. Enteroscopy in the diagnosis
and management of celiac disease. Gastrointest Endosc Clin N Am. 2009
Jul;19(3):445–4460.