Advances in Gastrointestinal Endoscopy
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1 2014 Hospital Authority Convention Advances in Gastrointestinal Endoscopy Wai K. Leung, MD, FRCP Clinical Professor, Department of Medicine, University of Hong Kong Deputy Director, Integrated Endoscopy Center, Queen Mary Hospital Hong Kong
2 Advances in GI Endoscopy Diagnostic Image enhanced endoscopy New equipment/technique Therapeutic EUS guided drainage POEM and submucosal endoscopy RFA
3 Diagnostic Colonoscopy
4 Interval Cancer and Adenoma Detection Rate Corley DA, et al. NEJM 2014
5 Chromoendoscopy
6 Narrow band imaging (NBI)
7 Adenoma Yield and Miss Rate (NBI vs WL) Adenoma yield rate Adenoma miss rate Pasha SF et al. Am J Gastroenterol 2012
8 New NBI
9 New NBI vs White Light Colonoscopy P = 0.01 P = 0.02 RCT 360 patients Tandem Colonoscopy 50 % P = 0.9 P = 1.0 New NBI WL Adenoma Polyp Adenoma Miss Detection RateDetection Rate Rate Polyp Miss Rate Leung WK, et al. Am J Gastroenterol 2014
10 Adenoma Detection Rate (%) Endoscopist s Experience and Adenoma Detection P = P = NBI WL 10 0 Endoscopist Leung WK, et al. Am J Gastroenterol 2014
11 Third Eye Retroscope
12 FULL SPECTRUM ENDOSCOPY (FUSE) Grannlek I, DDW 2013
13 FUSE vs Standard colonoscopy Multi-center, tandem colonoscopy trial 185 patients completed Adenoma miss rate (per-lesion analysis) 7% in FUSE vs 41% in standard (P<0.0001) Standard: missed 20 adenomas (3 advanced) FUSE missed 5 adenoma (none advanced) Gralnek IM, et al. Lancet Oncol 2014
14 FUSE Colonoscopy
15 Virtual Histology
16 NBI International Colorectal Endoscopic (NICE) Classification Color Vessels NICE Criterion Type 1 Type 2 Surface pattern Same or lighter than background None, or isolated lacy vessels coursing across the lesion Dark or white spots of uniform size, or homogeneous absence of pattern Most likely pathology Hyperplastic Adenoma Browner relative to background (verify color arises from vessels) Brown vessels surrounding white structures Oval, tubular, or branched white structures surrounded by brown vessels Hewett DG et al. Gastroenterology 2012
17 Confocal Laser Endomicroscopy (CLE) Probe based CLE Compatible with standard endoscopes Applied anywhere in GI tract Barrett s esophagus Gastric IM Coeliac disease Colitis Colonic polyps Pancreaticobiliary strictures
18 pcle for indeterminate pancreaticobilary strictures malignant Sensitivity = 98% Specificity = 67% benign Meining A et al. GI Endosc 2011
19 In vivo molecular imaging Real time, simultaneous imaging at 488 nm and 660 nm Using different fluorescent dyes and proteins (e.g. AvB3 Integrin dyes, Sytox Green, GCaMP3. Colon crypts imaged after acryflavin and AngioSense 680 injection: Vessels are highlighted in red, and crypts in green
20 OPTICAL COHERENT TOMOGRAPHY (OCT) Scanning of esophagus 3mm deep 6cm long segment In 90 seconds
21 Small Bowel Endoscopy
22 Ladas SD, et al. Endoscopy 2010 SB capsule endoscopy systems
23 Panoramic View Capsule Endoscopy 4 camera facing the sides 11.3 x 31 mm fps 5fps for each camera (first 2h) 3fps for each camera after 2h Battery life up to 15 h Stores all images on-board
24
25 Magnetic guided CE Rey et al. Endoscopy 2010
26 Keller J, et al. GI Endosc 2011
27 NaviAid Balloon-Guided Enteroscopy Disposable add-on device attached to endoscopes with balloon and working channel for the advancing balloon
28 Capsule Endoscopy (PILLCAM Colon 2) 2 camera covering 172 each Adaptive frame rate 4 fps (stationary) 35 fps (motion) Long battery life >10h Wireless transmission
29 NEW IMAGE PROCESSING: FLEXIBLE SPECTRAL INTELLIGENT COLOR ENHANCEMENT (FICE) Eliakim R. Gastroenterol 2010
30 Polyp Size Estimation 14 mm 15 mm 14 mm 14 mm 30
31 Pillcam Colon 2 vs Colonoscopy International multicenter study N = 695 Adenoma >= 6mm >= 10mm Polyp >= 6mm >= 10mm Sensitivity 88% (82-93%) 92% (82-97%) 81% (77-84%) 80% (74-86%) Specificity 82% (80-83%) 95% (94-95%) 93% (91-95%) 97% (96-98%) Rex D, DDW 2013
32 Biliary Endoscopy
33 Indications of Direct Per-oral Cholangioscopy Indeterminate biliary strictures Indeterminate filling defects Equivocal cholangiogram findings Bile duct cancer, intraductal papillary mucinous neoplasia or biliary papillomatosis Hemobilia of unknown etiology Remnant stones after lithotripsy
34 Cholangioscopy - Spyglass Per-oral direct cholangioscope Single operator Approved by FDA in 2009
35 Direct Cholangioscopy using Ultraslim Gastroscope Weigt J et al. GI Endosc 2014
36 Endoscopic Ultrasound
37 EUS guided biliary and pancreatic duct drainage Intrahepatic approach Pancreatic approach Transgastric Transduodenal: Extrahepatic approach Rendezvous vs Direct access Perez-Miranda M, et al. Gastrointest Endosc Clin N Am 2012
38 Courtesy of Dr YT Lee
39 AXIOS stent Fully covered Large diameter with 2 large flanges Create an anastomotic conduit
40 Treatment of Acute Cholecystitis EUS guided transgastic placement of lumen-apposing metal stent to gallbladder Gallstone crushed by BML through gastroscope after 2 wk Stent removed after confirmed clearance of stone Itoi T, et al. GI Endosc 2014
41 Fully Covered Metal Stent for Lumen Apposition Transgastric EUS guided GB drainage Moon JH et al. GI Endosc 2014
42 Endoscopic Management of GIB
43 Hemostatic powder (Hemospray) Peptic ulcer bleeding Uncontrolled variceal bleeding Post-polypectomy bleeding Post-ESD bleeding
44 Hemospray for post-polypectomy bleeding Soulellis CA et al. GI Endosc 2013
45 Endoscopic Closure: Over-the-scope clip (OTSC)
46 Endoscopic Full-thickness Resection 20 patients with small <3cm gastric subepithelial tumors Endoscopic resection with laparoscopic control Perforation closed with over-the-scopeclip (OTSC) Schlag C et al. Endoscopy 2012
47 OTSC for Refractory UGIB 9 patients (GU 3 and DU 6) Primary success 100% Rebleeding in 3 Chan SM, et al. Endoscopy 2014
48 ESD
49 ESD Devices - Knife Triangular knife IT knife Hook knife Dual knife Flush knife
50 ESD Traction Device & Endoscopic Multitasking Platform ANUBISCOPE Cobra system Endolifter MASTER system
51 Per-oral endoscopic myotomy (POEM)
52 Per-oral endoscopic myotomy (POEM) Von Renteln D et al. Am J Gastroenterol 2012
53 Per-oral endoscopic myotomy (POEM) Mean myotomy length 9cm All patients had relief of dysphagia (a mean of 11.4 month follow up) Confirmed by post-op manometry and Ba swallow Swanstrom LL et al. Ann Surg 2012 High peri-op and post-op complications: Pneumothorax 25% Subcutaneous emphysema 56% Mediastinal emphsema 29.4% Pleural effusion 48.7% Atelectasis 49.6% Ren Z. Surg Endosc 2012
54 Submucosal Endoscopic Tumor Resection Inoue H et al, Endoscopy 2012
55 RADIOFREQUENCY ABLATION (RFA) FOR BARRETT S ESOPHAGUS Shaleen N et al. NEJM 2009
56 RFA FOR BARRETT S DYSPLASIA Shaleen N et al. NEJM 2009
57 RFA reduces risk of progression from LGD to HGD and Cancer Phoa KN, et al. JAMA 2014
58 Conclusions Image enhanced endoscopy offers the opportunity for better identification and characterization of GI mucosal abnormality. The FUSE colonoscopy may reduce adenoma missing rate of ordinary colonoscope. Despite the availabity of many new devices and interventions, controlled clinical trials are needed to verify the ultimate benefits of these advances.
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