Ioannis S. Papanikolaou1, 2, Peter D. Siersema2



Bibliography DOI 10.1055/s-0034-1391340 Endoscopy 2015; 47: 147–153 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X

The 22nd United European Gastroenterology (EUG) Week took place in Vienna in October 2014. The meeting offered a great opportunity to all those interested in gastrointestinal (GI) endoscopy to exchange clinical experiences, research trends, and scientific progress from all over the

world. This report will highlight some of the most interesting topics of GI endoscopy that were presented over the 3 days, and will briefly comment on them in light of the latest bibliographic data.

Corresponding author Ioannis S. Papanikolaou, MD, PhD Hepatogastroenterology Unit 2nd Department of Internal Medicine and Research Unit Attikon University General Hospital University of Athens Rimini 1 Athens 12462 Greece Fax: +30-210-5326422 [email protected]

Esophageal disease

gus attempted to assess the prevalence of eosinophilic esophagitis (including esophageal eosinophilia and lymphocytic esophagitis), an entity in which intraepithelial lymphocytes infiltrate the esophageal mucosa [6]. A total of 95 patients underwent upper gastrointestinal (GI) endoscopy with histology and were evaluated by magnifying narrow-band imaging (NBI). It was found that a beige color, increased intrapapillary capillary loops, and invisibility of submucosal vessels were features characteristic of eosinophilia or severe lymphocytic infiltration. These findings are in contrast to the “characteristic” findings of conventional endoscopy (mucosal rings, linear furrows, white exudates, and narrow caliber or stenosis), which are also apparent in gastroesophageal reflux disease. These results suggest that, using pathology as gold standard, magnifying NBI could be more reliable than standard endoscopic features in predicting eosinophilic esophagitis, esophageal eosinophilia, or lymphocytic esophagitis. Ablation of Barrett’s esophagus by thermal methods, mainly radiofrequency ablation and argon plasma coagulation (APC), is an established practice, although it carries a risk of stricture formation. A German team recently published an ex vivo porcine study with a small number of cases, which advocated the use of hybrid APC (i. e. APC with prior submucosal fluid injection) to overcome this problem [7]. The same group presented data from a series of 60 patients (50 were finally analyzed) with Barrett’s esophagus who underwent ablation with hybrid APC [8]. Complete ablation of Barrett’s esophagus was achieved in

Hepatogastroenterology Unit, 2nd Department of Internal Medicine and Research Unit, Attikon University General Hospital, University of Athens, Greece 2 Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands


The advent of peroral endoscopic myotomy (POEM) for the treatment of achalasia and other esophageal disorders is a topic that has attracted a number of abstracts in recent years [1, 2]. As the method has come of age, various reports regarding its indications, effectiveness, and safety have started to emerge [3]. An intriguing abstract from Italy reported the outcomes of POEM as a rescue therapy after failed surgical treatment (Heller myotomy) [4]. Data from 5 patients who underwent POEM after a failed myotomy were compared with those of 151 patients who underwent POEM exclusively. Both groups were similar with regard to operating time, length of the submucosal tunnel, length of myotomy, and mean postoperative hospital stay. No perioperative complications occurred in the failed Heller group, but one patient developed an esophageal stricture. At 3-month follow-up, all patients in the failed Heller group demonstrated significantly improved objective functional measures, including Eckardt score, body weight, basal lower esophageal sphincter pressure, and 4-second integrated residual pressure, although some reflux occurred in three of the five patients [4]. These results are in line with recently published data, and demonstrate the feasibility, safety, and effectiveness of POEM as a therapeutic alternative in cases of failed Heller myotomy [5]. Similar to last year, only a few abstracts on eosinophilic esophagitis were presented. An interesting report from Sweden in adults presenting with dysphagia and/or food impaction in the esopha-

Papanikolaou Ioannis S et al. UEG Week 2014 highlights … Endoscopy 2015; 47: 147–153

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UEG Week 2014 highlights: putting endoscopy into perspective


96 % (48/50), and 78 % (39/48) were histopathologically disease free; there were no treatment-related strictures. It therefore seems that hybrid APC could be an effective modality for ablation of Barrett’s esophagus, although the current study was only a pilot study and thus further data are required.

Endoscopic treatment !

Endoscopic mucosal resection (EMR) is often the procedure of choice when it comes to treating dysplastic or early neoplastic lesions in the GI tract. However, when dealing with larger lesions (especially ≥ 20 mm), EMR cannot always guarantee en bloc resection or assessment of the resection margin, as only a piecemeal EMR can be performed for these lesions [9]. In this setting, endoscopic submucosal dissection (ESD) is an alternative and is now being increasingly utilized. However, as experience with ESD is still relatively limited, EMR is performed on a large scale in Western centers, even for larger esophageal lesions [10]. A multicenter study from Spain (17 centers with 881 EMRs; 660 were prospectively registered) assessed the complications of piecemeal EMR after treatment of large colorectal lesions [11]. Delayed bleeding occurred in 4 % of cases and was associated with an increased lesion size, proximal lesions, age > 75 years, high American Society of Anesthesiologists classification, and aspirin therapy. In contrast, perforations occurred in 1.2 %, without any associated factors being identified. Apart from one bleed that was treated by vascular interventional radiology and two perforations that required surgery, all complications were managed endoscopically [11]. These and other favorable results probably explain why many Europeans keep practicing EMR, even when ESD might be more appropriate. As mentioned, ESD enables en bloc resection of lesions regardless of their size and could be considered for lesions ≥ 20 mm; however, it requires a more cumbersome training, has a prolonged procedure time, and carries an increased risk of complications, although data from meta-analyses directly comparing EMR with ESD are scarce [9]. An Italian metaanalysis presented at the UEG Week attempted to fill this gap [12]. Eight published studies (7 retrospective, 1 prospective) with a total of 4023 lesions (2104 treated with ESD, 1919 with EMR) were included. Although “harder” cases were treated with ESD (larger lesions, more nongranular lateral spreading tumors and sm1-adenocarcinomas), the data showed that ESD was able to achieve higher en bloc resection and curative resection rates, and lower local recurrence rates, at the cost of a much longer procedure times (89 ± 33 minutes vs. 22 ± 7 minutes) and more perforations. These data agree with those published previously [9], and advocate wider implementation of ESD in the West. Until then, some “compromises” have been proposed (e. g. ESD with snaring) [13]. Another endotherapy technique – the novel knife-assisted resection method – has also been introduced as an ideal method for the treatment of large and refractory colonic polyps (especially flat lesions sized 20 – 50 mm) in the West [14]. The technique includes submucosal injection followed by mucosal incision with a dual knife (KD-650L; Olympus, Tokyo, Japan), followed by some submucosal dissection and snare-assisted resection. A total of 127 polyps with a mean size of 46 mm (range 20 – 170 mm), including 27 % with scars from previous resection attempts, were treated in this way. The en bloc resection rate was 46 % overall and 88 % for polyps < 50 mm. Complications occurred in 8.6 % (3.9 % bleeds, 3.1 % diathermia damage to the muscle layer, and

0.78 % perforations), and the recurrence rate was 13 % (significantly lower for polyps < 50 mm and nonscarred ones). In another study, the feasibility and effectiveness of full-thickness resection using a novel over-the-scope device (Full Thickness Resection Device; Ovesco, Tubingen, Germany) was demonstrated in the lower GI tract in 21 patients with so-called “difficult” indications (including some recurrent or incompletely resected adenomas, various cases with a nonlifting sign, adenomas of the appendix, etc.) [15]. Histologically complete resection was achieved in 85 % of cases, with no perforations or bleedings. The study adds significant clinical findings to a topic in which most publications are either experimental animal studies or small series [16, 17].

GI bleeding !

GI bleeding and hemostasis have always been an interesting topic in GI endoscopy, as they represent a area in which research and progress can soon be translated into everyday clinical practice. Following last year’s trend, the 2014 meeting had a few interesting abstracts related to GI bleeding [1, 2]. One of the most important subjects presented was a novel hemostatic tool called Hemospray (Cook Medical, Winston Salem, North Carolina, USA). Hemospray is an inorganic clotting nanopowder, which can be sprayed onto a bleeding site using a 10-Fr catheter to achieve hemostasis in GI bleeding from peptic ulcers, varices, cancer, and other rare causes or uncontrollable diffuse hemorrhage [18 – 21]. In contrast to previous years, where presented studies included only small patient numbers [22, 23], this year’s abstracts incorporated larger groups of patients. An interesting multicenter study from France, Switzerland, and Monaco (46 endoscopists in 17 centers) reported the results of Hemospray use in real-life situations in a total of 96 patients, with 31 tumor-related, 43 ulcer, 8 post-EMR, and 14 miscellaneous bleeding lesions [24]. The agent was used as first-line treatment in 51.6 % of cases and as rescue therapy in 48.4 %. Its application was considered to be very easy or easy in 89 %, and moderately easy or difficult in 11 % of cases. The rate of immediate efficacy was 93.6 %, and there was no recurrence in 74 % of cases. These results are generally in line with another published two-center study [18], especially in terms of successful initial hemostasis, although the rebleeding rate was higher in the multicenter study. However, the number of patients was lower in the two-center study and Hemospray was mostly used as salvage therapy. The indications for Hemospray use have broadened to include portal hypertensive bleeding (mainly variceal) [19]. Initial favorable data from a two-center, prospective, pilot study (nine patients) with acute variceal bleeding was presented at the 2013 meeting and published earlier in 2014 [23, 25]. At UEG Week 2014, the same group presented updated results from a larger number of patients (30 /38 enrolled; 83.4 % with esophageal, 10 % with gastric, and 6.6 % with duodenal varices) [26]. Primary hemostasis was achieved in all cases, but one patient had recurrent hematemesis 6 hours post-therapy and was treated by emergency band ligation; the clinical hemostasis rate was therefore 96.7 % (29/30). Curiously, bleeding was active during endoscopy in only 43.4 % of cases, a rather low rate for a method often used as rescue therapy. It seems that Hemospray is here to stay and will probably prove to be an effective modality in treating different types of bleeding causes. Finally, a large multicenter, international study performed in three countries (UK, Canada, and Australia) reported a new risk

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score for upper GI bleeding, which allows the triaging of both low- and high-risk patients [27]. The score demonstrated better performance than both the Rockall score (apart from mortality assessment) and the Glasgow–Blatchford score. It is impressive that the authors included a large number of patients (10 639 to derive the scoring system and 1606 for external validation).

Colonoscopy !

Colonoscopy is traditionally a field of endoscopy that is extremely well represented at the UEG Week. Improvements in colonoscopy quality have a direct beneficial impact on society. Improving screening and surveillance colonoscopy for the prevention of colorectal cancer remains a field of special interest for endoscopists, and topics such as quality, technical innovations, and improvement in polyp detection are on the research agenda [28 – 30]. It is therefore not surprising that some “new kids” appeared on the technological “block” this year, with quite a few interesting abstracts. For example, retroflexion in the right-sided colon or use of retrograde viewing devices have been advocated for some years to improve adenoma detection in the proximal large bowel [31, 32]. Limitations to these techniques, including technical difficulties in performing retroflexion, absence of high definition view, increased costs, or absence of therapeutic capabilities of retrograde devices, have been addressed by the development of the RetroView (Pentax Medical, Tokyo, Japan), a novel colonoscope with an enhanced retroflex section (i. e. a shorter bending section and a larger tip deflexion). The new colonoscope was tested for feasibility and safety of segmental retroflexion throughout the entire colon in a single-center, single-operator study from Ecuador, which included 48 patients [33]. The retroflexed withdrawal success rate was 98 % in the right colon, 100 % in the transverse colon, 100 % in the left colon, 81 % in the sigmoid colon, and 100 % in the rectum. In total, 67 % more adenomas were detected in retroflexion (2 in the right and 4 in the transverse colon, out of a total of 9). Despite questions regarding performance in this study (including the small number of adenomas detected, and missed polyps of 15 mm in forward view), these initial results seem intriguing. Another technical advancement in colonoscopy is the G-EYE colonoscopy system (NaviAid; Smart Medical Systems Ltd., Ra’anana, Israel). The system consists of a standard colonoscope with an integrated, reusable, balloon at its distal end. The colonoscope is inserted with the balloon deflated until it reaches the cecum, at which point the balloon is inflated and the system is withdrawn. This allows the intestinal folds to be straightened [34]. Initial data from 74 patients were reported at the 2013 meeting [1]. Since then, more evidence has been collected, including a prospective multicenter cohort study of 222 patients who underwent either G-EYE colonoscopy (n = 105) or conventional high definition colonoscopy (n = 117) [35]. A significant increase in adenoma detection rate was reported with the new system (35.4 % vs. 23.5 %) as well as an increased proportion of adenomas per patient (0.63 vs. 0.36). Another report from Germany, comparing G-EYE with conventional colonoscopy and including 45 patients, reported an increase in polyp detection rate in favor of G-EYE (with a 100 % additional detection of adenomas) and a significant reduction in polyp miss rate (18.6 % for G-EYE vs. 48 % for conventional colonoscopy) [36]. One of the study’s most interesting features is that although the design was a back-to-back study, the endoscopists changed after each withdrawal in order

to reduce bias, which has been a criticism of previous tandem studies [37]. Another German study assessed the Endocuff (Medivators Inc., Minneapolis, Minnesota, USA), a device with small flexible “spikes,” which is attached to the distal tip of the colonoscope and opens the bowel lumen during withdrawal by straightening musocal folds. After a favorable initial report [38], the device was tested in a multicenter, randomized trial (3 tertiary centers with 652 colorectal screening patients who underwent colonoscopy with or without Endocuff) [39]. A significant increase was found in favor of the Endocuff in terms of polyp and adenoma detection rates, as well as overall number of polyps detected per patient. Another technological advancement is the Full Spectrum Endoscopy colonoscopy system (FUSE; EndoChoice, Alpharetta, Georgia, USA), which allows 330° viewing of the colonic mucosa. Favorable results were presented during the 2013 meeting [1] and were published recently [40]. Additional results were presented in poster format this year. The authors calculated that although FUSE increased adenoma detection rates and impacted recommended postpolypectomy surveillance intervals, it was still cost-effective because costs associated with more frequent postpolypectomy surveillance are counter-balanced by a significant reduction in costs related to colorectal cancer treatment [41]. Another poster presented the results of a tandem study, which showed that FUSE detects significantly more missed polyps (overall and right sided) [42]. Finally, the controversial issue of prophylactic clipping to prevent postpolypectomy bleeding was addressed in a Japanese, multicenter, randomized study (7 centers including 1499 patients with 3365 polyps) [43]. The study showed that clipping was noninferior to nonclipping. A design issue in this study was that clipping of oozing bleeding or visible vessels was characterized as “prophylactic,” whereas spurting bleeding was an exclusion criterion.

Small-bowel enteroscopy !

Previous UEG meetings have seen a decline in the number of presentations on endoscopic modalities used for the examination of the small bowel [1], and this trend continued in 2014. The most common small-bowel topic is now Crohn’s disease and its management. Several abstracts on video capsule endoscopy (VCE) were presented. For example, a novel VCE system for Crohn’s disease (PillCamCD; Given Imaging, Yoqneam, Israel) was designed to examine the whole GI tract, as lesions in Crohn’s disease can be found from the oral cavity to the anus. The diagnostic yield of PillCamCD was prospectively compared with that of ileocolonoscopy in a multicenter, international, cohort study, which included 76 patients with known Crohn’s disease who presented with signs and symptoms of active disease [44]. VCE was equally effective in identifying active Crohn’s disease in the colon and terminal ileum. Furthermore, it identified overall more patients with active Crohn’s disease, as ileocolonoscopy is not able to visualize the proximal small bowel. However, it should be noted that there were 38 screening failures and 3 complications (1 bowel obstruction due to VCE retention, 1 patient with abdominal pain due to bowel preparation, and 1 episode of fever, nausea and vomiting, abdominal pain, and bloating related to the patency capsule that was used prior to VCE examination). Balloon-assisted enteroscopy in everyday clinical management of small-bowel pathologies allows endoscopic balloon dilation

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(EBD) to be performed for strictures in Crohn’s disease that are beyond the reach of colonoscopy, and the procedure can be used as an alternative to surgery [45]. This was shown in a prospective, open-label, cohort study performed in 23 centers in Japan, which included 112 patients with symptomatic Crohn’s disease-related small-bowel strictures [46]. Apart from complications in 2 cases (bleeding that was managed conservatively) and 10 cases in which EBD could not be performed for various reasons, EBD was found to be effective and safe. Finally, an area that was extensively addressed this year was that of the role of confocal laser endomicroscopy (CLE) in the management of Crohn’s disease. CLE enables in vivo microscopic evaluation of the bowel mucosa, making it possible to identify even subtle changes. It thus could act as a useful adjunct to conventional endoscopy [47]. This was illustrated in an interesting study, in which the endoscope-based CLE system (EC3830FK; Pentax) was used in 49 patients (38 with Crohn’s disease, 11 controls) [48]. CLE diagnosed microscopic pathology in the terminal ileum of those with Crohn’s disease, even in patients with silent disease.

ERCP and pancreaticobiliary disorders !

Endoscopic retrograde cholangiopancreatography (ERCP) and pancreaticobiliary topics remained highly represented at the 2014 meeting, continuing the trend observed from previous meetings. Difficult cannulation, prophylaxis of post-ERCP pancreatitis (PEP), balloon dilation, and biliary drainage were topics that were covered in this year’s most interesting abstracts. Difficult cannulation of the common bile duct (CBD) remains a relatively common problem, and occurs during 10 % – 15 % of procedures [49, 50]. In these cases, the endoscopist might resort to various alternatives, including conventional precut sphincterotomy and infundibulotomy, the early initiation of which is recommended in order to avoid complications [51]. A prospective study from France including 113 patients who underwent ERCP for various indications assessed infundibulotomy with regard to PEP and its effectiveness in biliary cannulation [52]. Data showed that infundibulotomy could increase ERCP success rates from 71 % to 95.6 %, with a fair PEP rate, provided that it is initiated early (8 /13 cases of PEP occurred when infundibulotomy was performed after > 15 minutes of CBD cannulation attempts). However, it should also be noted that the “conventional” cannulation rate in the study appeared to be relatively low (70.8 %). Another “hot” topic attracting interest at UEG Week 2014 was EBD of the sphincter of Oddi using various types of balloons, before or after endoscopic sphincterotomy (EST) [53, 54]. A Korean group retrospectively assessed the effectiveness and safety of EBD with large (12 – 18 mm) balloons compared with additional EST for the treatment of recurrent choledocholithiasis in 89 patients with a non-full EST [55]. Complete stone removal was achieved in all cases, but mechanical lithotripsy was required for complete removal of large bile duct stones in fewer cases in the EBD group than in the group with additional EST (16.9 % vs. 36.7 %). Moreover, EBD was associated with a significantly lower postprocedural bleeding rate (1.7 % vs. 13.3 %). PEP was not significantly different between the two groups. Previously published retrospective studies on EBD and recurrent choledocholithiasis (this time compared with complete EST) also support its effectiveness, and it may even prevent future recurrence of choledocholithiasis [56].

Another interesting area is the diagnosis and management of biliary strictures of indeterminate etiology, for which data are, to some extent, cloudy [57, 58]. A large German cohort of such patients was presented, in which 234 patients underwent ERCP with intraductal ultrasound (IDUS), computed tomography (CT) or endoscopic ultrasonography (EUS) for an indeterminate stricture or filling defect of the CBD [59]. Surgical histopathology or long-term follow-up served as the gold standard. ERCP combined with IDUS performed better than EUS and CT, with accuracies for detecting malignancy of 91 % (ERCP/IDUS), 59 % (endoscopic transpapillary forceps biopsies [ETP]), 92 % (ERCP/IDUS + ETP), 74 % (EUS), and 73 % (CT). Endotherapy of biliary strictures (benign or malignant) with stenting is another topic that has attracted interest in most recent UEG Week meetings. A controversial topic that led to some discussion at the 2014 meeting was the use of preoperative biliary drainage of jaundiced patients who have resectable pancreatic neoplasia. The topic is not new, and preoperative biliary drainage/stenting has been compared with early pancreaticoduodenectomy, with most data supporting the latter procedure [60 – 62]. However, stenting might still be considered in cases of logistical delays to surgery or the need to initiate neoadjuvant chemotherapy. The use of metal or plastic stents was the subject of a Dutch multicenter, randomized trial, in which complication rates were assessed in 53 patients who underwent preoperative drainage with metal stents vs. 102 patients who received plastic stents [63]. Complications were more common with plastic stents (46 %) than metal stents (24 %). Thus, although patients undergoing early surgery were likely to fare better than those undergoing stenting, metal stents were associated with fewer complications than plastic stents when drainage was performed. These results are in line with previous data that also favored metal stents for this indication [64]. A Spanish randomized trial was also presented advocating the use of fully covered metal stents over plastic stents for preoperative endoscopic biliary drainage in 63 patients with potentially resectable periampullary tumors [65]. Finally, with regard to pancreatic stenting for prophylaxis of PEP, a report in which 1163 patients undergoing pancreatic stenting were included (out of a total 47 486 ERCPs registered in a Swedish database) supported the use of pancreatic stents with a diameter larger than 5 Fr [66]. This is noteworthy, as most previously published data support smaller-caliber pancreatic stents [51, 67, 68]. Nonetheless, caution is needed even when the indication is to prevent PEP. A prospective study from Hungary stressed that pancreatic stenting should be done carefully, as it can cause its own complications [69]. In total, 317 patients at high risk for PEP were considered for prophylactic pancreatic stenting. Insertion was not successful in 9.15 % of cases. Moreover, complications occurred in 2.78 % (eight patients) of the successfully stented cases, including five early stent dislodgements (these patients all developed mild PEP) and three proximal stent migrations (all stents were straight with internal flaps; extraction was successful in 2 patients but impossible in the third, in whom distal pancreatectomy was performed). Stents with an internal flap and outer pigtail end (Freeman type) seemed to help in avoiding this condition.

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The pivotal role of EUS as an important diagnostic and therapeutic tool is no longer disputed. Some interesting abstracts on EUSguided diagnostics were presented at UEG Week 2014. For example, contrast-enhanced EUS (CE-EUS) is a new advancement in EUS that allows better evaluation of a lesion’s vascularity by the interpretation of signals deriving from microbubbles that are produced when an intravenous contrast medium is injected. Previous studies have reported on the effectiveness of CE-EUS, especially for a pancreatic diagnosis [70, 71]. In line with these reports, a prospective study from Japan, which included 147 patients, supported the use of CE-EUS for pancreatic solid lesions [72]. Histological diagnosis from the surgical specimen or EUSguided fine-needle aspiration (EUS-FNA), as well as international consensus criteria for autoimmune pancreatitis, served as gold standards. Based on lesion vascularity, CE-EUS aided in differentiating between ductal carcinomas (hypovascular pattern in 95 %), autoimmune pancreatitis (isovascular in 89 %), neuroendocrine tumors (hypervascular in 75 %), inflammatory masses (isovascular in 73 %), invasive intraductal papillary mucinous neoplasms (IPMNs) (hypovascular in 60 %), and acinar carcinomas (all isovascular). Most importantly, hypovascularity determined by CE-EUS could predict ductal carcinoma with a sensitivity and accuracy of 95 % and 89 %, respectively. The introduction of EUS-FNA has definitely broadened the frontiers of EUS. EUS-FNA has evolved into an irreplaceable tool in diagnostics and therapy both within and outside of the GI tract [73]. A plethora of needles has been introduced for EUS-FNA, with various sizes and designs in order to obtain better tissue samples. The choice of needle is therefore of pivotal importance and was the topic of various abstracts at the 2014 meeting. For example, a novel 25-G needle with a newly added core trap (EchoTip ProCore; Cook Medical) was prospectively compared with its standard 25-G counterpart in a multicenter, randomized trial from Japan (8 centers, 214 patients with solid pancreatic tumors) [74]. Tissue acquisition and definite histological diagnosis after a single pass significantly favored use of the new needle (90.6 % and 81.1 % vs. 79.6 % and 69.4 %, respectively). Contrary to these results, a meta-analysis of 21 studies involving 1617 patients failed to show a significant difference in tissue adequacy, diagnostic accuracy, core tissue acquisition, or necessary number of passes between ProCore (19, 22, and 25 G) and standard EUSFNA needles [75]. Although the studies included were extremely heterogeneous in design and end points, these data should be taken into account. The choice of the “perfect” needle (if such a needle for all indications exists) is probably influenced by many factors including endosonographer experience. Moreover, the cost of each needle is also a significant factor that should not be underestimated, especially with the increasingly limited resources available to health care systems in many countries. Finally, another international randomized crossover study came to similar discouraging conclusions regarding the performance of another “improved” EUS needle, the EZ-Shot 2 (Olympus). This needle has a special side port to improve EUS-FNA. After 120 needle passes in 30 patients with pancreatic masses, the researchers concluded that what really counted was how many passes the endosonographer could perform. Cellularity was found to be adequate after 4 passes in all specimens, and a correct diagnosis was made in 96 % of cases [76]. Another novel advancement in EUS, which has occurred as a result of EUS-FNA practice, is needle-based confocal laser endomi-

croscopy (nCLE). EUS-FNA is performed first, followed by advancement of a special miniprobe through the needle for realtime in vivo endomicroscopy. The method was presented at the 2013 meeting and has since shown encouraging results in pancreatic lesions, mostly cystic [1, 77, 78]. At the 2014 meeting, a multicenter, prospective study was presented in which nCLE was evaluated in pancreatic masses. Images from 34 patients were obtained and compared with histological results acquired from EUS-FNA; nCLE was shown to aid in differentiating pancreatic malignancy from normal tissue, as well as adenocarcinomas from neuroendocrine tumors [79]. However, as was highlighted last year, the results from such initial studies on nCLE should be evaluated with caution, as the method still needs to be validated, and the interobserver interpretation requires improvement. The latter was done with computer-aided diagnostic software (SmartAtlas), which was developed to assist in the interpretation of nCLE videos, particularly in differentiating serous cystadenomas from IPMNs [80]. A total of 29 nCLE video sequences were collected from 18 patients (12 with serous cystadenomas, 6 with IMPNs). The computer-aided classification, which aimed to maximize specificity with an acceptable sensitivity, produced a specificity of 95.5 % and a sensitivity of 85.7 %. In addition, accuracy, positive predictive value, and negative predictive value were 93.1 %, 85.7 %, and 95.5 %, respectively. With regard to therapy, EUS-FNA could play a therapeutic role within or even outside of the GI tract [81]. Among various new therapeutic applications of EUS was an intriguing video case that illustrated the delivery of intra-arterial chemotherapy by EUS for the treatment of nonresectable hepatic metastasis in which systematic chemotherapy had previously failed [82]. Obviously, more data are needed. Competing interests: None

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34 Gralnek IM, Suissa A, Domanov S. Safety and efficacy of a novel balloon colonoscope: a prospective cohort study. Endoscopy 2014; 46: 883 – 887 35 Halpern Z, Ishaq S, Neumann H et al. G-EYE colonoscopy significantly improves adenoma detection rates – initial results of a multicenter prospective cohort study. United European Gastroenterol J 2014; 2: 01A43 36 Rey JW, Haschemi J, Tresch A et al. G-EYE advanced colonoscopy for increased polyp detection rate – randomized tandem study with different endoscopist. United European Gastroenterol J 2014; 2: A43 37 Dawwas MF. Full-spectrum colonoscopy for adenoma detection. Lancet Oncol 2014; 15: e244 – 245 38 Lenze F, Beyna T, Lenz P et al. Endocuff-assisted colonoscopy: a new accessory to improve adenoma detection rate? Technical aspects and first clinical experiences Endoscopy 2014; 46: 610 – 614 39 Floer M, Biecker E, Ameis D et al. Endocuff-assisted colonoscopy significantly increases the adenoma detection rate: a randomized controlled multicenter trial with 652 patients. United European Gastroenterol J 2014; 2: A44 40 Gralnek IM, Siersema PD, Halpern Z et al. Standard forward-viewing colonoscopy versus full-spectrum endoscopy: an international, multicentre, randomised, tandem colonoscopy trial. Lancet Oncol 2014; 15: 353 – 360 41 Hassan C, Gralnek IM. The cost-effectiveness of “Full Spectrum Endoscopy (Fuse)” colonoscopy for colorectal cancer screening. United European Gastroenterol J 2014; 2: A232 42 Papanikolaou IS, Apostolopoulos P, Beintaris I et al. Full spectrum endoscopy vs. rraditional forward-viewing colonoscopy with andwithout right-colon retroflexion: a randomized, bicentric back-toback study. United European Gastroenterol J 2014; 2: A330 – A331 43 Matsumoto M, Kato M, Sakamoto N. Multicenter randomized controlled study to assess the preventive effect of prophylactic clipping for post-polypectomy bleeding. United European Gastroenterol J 2014; 2: A86 44 Helper D, Malik P, Havranek R et al. The novel PillCam Crohn’s disease capsule demonstrates similar diagnostic yield as ileocolonoscopy in patients with active Crohn’s disease – a prospective multicenter international cohort study. United European Gastroenterol J 2014; 2: A19 45 Hirai F, Beppu T, Sou S et al. Endoscopic balloon dilatation using double-balloon endoscopy is a useful and safe treatment for small intestinal strictures in Crohn’s disease. Dig Endosc 2010; 22: 200 – 204 46 Hirai F, Matsumoto T, Matsui T. Efficacy of endoscopic balloon dilation for small bowel strictures in patients with Crohn’s disease: a nationwide, multi-center, open-label, prospective cohort study. United European Gastroenterol J 2014; 2: A12 47 Tontini GE, Vecchi M, Neurath MF et al. Advanced endoscopic imaging techniques in Crohn’s disease. J Crohns Colitis 2014; 8: 261 – 269 48 Karstensen JG, Brynskov J, Riis LB et al. Confocal laser endomicroscopy – a new method for endoscopic assessment of Crohn’s disease. United European Gastroenterol J 2014; 2: A10 – A11 49 Peng C, Nietert PJ, Cotton PB et al. Predicting native papilla biliary cannulation success using a multinational Endoscopic Retrograde Cholangiopancreatography (ERCP) Quality Network. BMC Gastroenterol 2013; 13: 147 50 Lopes L, Dinis-Ribeiro M, Rolanda C. Safety and efficacy of precut needle-knife fistulotomy. Scand J Gastroenterol 2014; 49: 759 – 765 51 Dumonceau JM, Andriulli A, Elmunzer BJ et al. Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) guideline – updated June 2014. Endoscopy 2014; 46: 799 – 815 52 Alhameedi R, Di Fiore A, Antonietti M et al. Contribution of early needleknife infundibulotomy in difficult ERCP: a prospective study. United European Gastroenterol J 2014; 2: A2 – A3 53 Yang XM, Hu B. Endoscopic sphincterotomy plus large-balloon dilation vs endoscopic sphincterotomy for choledocholithiasis: a meta-analysis. World J Gastroenterol 2013; 19: 9453 – 9460 54 Kogure H, Tsujino T, Isayama H et al. Short- and long-term outcomes of endoscopic papillary large balloon dilation with or without sphincterotomy for removal of large bile duct stones. Scand J Gastroenterol 2014; 49: 121 – 128 55 Kim D, Song G, Lee B et al. Endoscopic papillary large balloon dilation (EPLBD) versus additional full endoscopic sphincterotomy (EST) for the endoscopic removal of recurrent large bile duct stones after nonfull EST. United European Gastroenterol J 2014; 2: A6 56 Tsai TJ, Lai KH, Lin CK et al. Role of endoscopic papillary balloon dilation in patients with recurrent bile duct stones after endoscopic

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sphincterotomy. J Chin Med Assoc In press 2014: DOI 10.1016/j. jcma.2014.08.004 Khashab MA, Fockens P, Al-Haddad MA. Utility of EUS in patients with indeterminate biliary strictures and suspected extrahepatic cholangiocarcinoma (with videos). Gastrointest Endosc 2012; 76: 1024 – 1033 Victor DW, Sherman S, Karakan T et al. Current endoscopic approach to indeterminate biliary strictures. World J Gastroenterol 2012; 18: 6197 – 6205 Heinzow HS, Kammerer S, Domagk D et al. Comparative analysis of ERCP, IDUS, EUS and CT in predicting malignant bile duct strictures – results of a tertiary referral center with 234 patients. United European Gastroenterol J 2014; 2: A5 – A6 van der Gaag NA, Rauws EA, van Eijck CH et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med 2010; 362: 129 – 137 Fang Y, Gurusamy KS, Wang Q et al. Meta-analysis of randomized clinical trials on safety and efficacy of biliary drainage before surgery for obstructive jaundice. Br J Surg 2013; 100: 1589 – 1596 Arkadopoulos N, Kyriazi MA, Papanikolaou IS et al. Preoperative biliary drainage of severely jaundiced patients increases morbidity of pancreaticoduodenectomy: results of a case-control study. World J Surg 2014; 38: 2967 – 2972 Tol J, van Hooft J, Timmer R et al. Metal or plastic stents for preoperative biliary drainage in resectable periampullary cancer: prospective multicenter study. United European Gastroenterol J 2014; 2: A17 Cavell LK, Allen PJ, Vinoya C et al. Biliary self-expandable metal stents do not adversely affect pancreaticoduodenectomy. Am J Gastroenterol 2013; 108: 1168 – 1173 Gonzalez-Huix F, Alburquerque MA, Figa M et al. Metallic vs. plastic stent in the preoperative treatment for biliary obstruction of resectable periampullary tumours: a randomized controlled trial. United European Gastroenterol J 2014; 2: A126 Enochsson L, Olsson G, Swahn F et al. Pancreatic stents with a diameter exceeding five French seem to have a protective effect on post ERCP pancreatitis – a nationwide, register-based study. United European Gastroenterol J 2014; 2: A117 – A118 Brackbill S, Young S, Schoenfeld P et al. A survey of physician practices on prophylactic pancreatic stents. Gastrointest Endosc 2006; 64: 45 – 51 Afghani E, Akshintala VS, Khashab MA et al. 5-Fr vs. 3-Fr pancreatic stents for the prevention of post-ERCP pancreatitis in high-risk patients: a systematic review and network meta-analysis. Endoscopy 2014; 46: 573 – 580 Dubravcsik Z, Madacsy L, Hritz I et al. Complications of prophylactic pancreatic stenting used for the prevention of post-ERCP pancreatitis with regards to stent types: results of a prospective, controlled study. United European Gastroenterol J 2014; 2: A117 Gincul R, Palazzo M, Pujol B et al. Contrast-harmonic endoscopic ultrasound for the diagnosis of pancreatic adenocarcinoma: a prospective multicenter trial. Endoscopy 2014; 46: 373 – 379

71 Ishikawa T, Itoh A, Kawashima H et al. Usefulness of EUS combined with contrast-enhancement in the differential diagnosis of malignant versus benign and preoperative localization of pancreatic endocrine tumors. Gastrointest Endosc 2010; 71: 951 – 959 72 Yamashita Y, Ueda K, Abe H et al. Usefulness of contrast-enhanced endoscopic ultrasonography for differential diagnosis of panceatic solid lesions: a single-center prospective study. United European Gastroenterol J 2014; 2: A21 73 Mekky MA, Abbas WA. Endoscopic ultrasound in gastroenterology: from diagnosis to therapeutic implications. World J Gastroenterol 2014; 20: 7801 – 7807 74 Nebiki H, Yanagisawa A, Yasukawa S et al. Prospective multicenter randomized controlled trial of histological diagnostic yield comparing 25G EUS-FNA needles with and without a core trap in solid pancreatic masses: analysis of factors affecting tissue acquisition and diagnostic accuracy. United European Gastroenterol J 2014; 2: A21 75 Bang JY, Hasan M, Hawes R et al. Endoscopic ultrasound-guided tissue acquisition: meta-analysis comparing the ProCore and standard fine needle aspiration needles. United European Gastroenterol J 2014; 2: A36 76 Ang TL, Kwek A, Seo DW et al. A prospective randomized cross-over study of the difference in diagnostic yield between EUS FNA needles with and without a side port in pancreatic masses. United European Gastroenterol J 2014; 2: A37 77 Konda VJ, Aslanian HR, Wallace MB et al. First assessment of needlebased confocal laser endomicroscopy during EUS-FNA procedures of the pancreas (with videos). Gastrointest Endosc 2011; 74: 1049 – 1060 78 Napoléon B, Lemaistre AI, Pujol B et al. A novel approach to the diagnosis of pancreatic serous cystadenoma: needle-based confocal laser endomicroscopy. Endoscopy In press 2014: DOI 10.1055/s-00341390693 79 Giovannini M, Caillol F, Lucidarme D et al. Needle based confocal laser endomicroscopy (NCLE) for the diagnosis of pancreatic masses: correlation between PCLE and histological criteria (Contact study). United European Gastroenterol J 2014; 2: A22 80 Kohandani Tafreshi M, Napoléon B, Lemaistre A-I et al. Smart atlas for supporting the interpretation of needle-based confocal laser endomicroscopy (NCLE) of pancreatic cysts: first classification results of a computer-aided diagnosis software based on image recognition. United European Gastroenterol J 2014; 2: A37 81 Kinzel J, Pichetshote N, Dredar S et al. Bleeding from a duodenal varix: a unique case of variceal hemostasis achieved using EUS-guided placement of an embolization coil and cyanoacrylate. J Clin Gastroenterol 2014; 48: 362 – 364 82 Artifon ELA, Carneiro FO, Sakai CM et al. EUS-guided hepatic intra-arterial chemoembolization. United European Gastroenterol J 2014; 2: A80

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UEG Week 2014 highlights: putting endoscopy into perspective.

The 22nd United European Gastroenterology (EUG) Week took place in Vienna in October 2014. The meeting offered a great opportunity to all those intere...
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