Foreword

Thierry Ponchon

Dear colleagues and friends,

In this issue of EIO, we have 14 original manuscripts from 9 different countries (from different continents): Japan, Australia, Brasil, USA, Egypt, Austria, Belgium, Germany and France, plus 3 editorials.

Two papers describe how sedation can and should be administered and monitered in case a non-anesthesiologist is in charge, especially during lengthy procedures such as ESD (the role of bispectral index monitoring, the role of nonanesthesiologist-administered propofol). The diagnosis of dysplasia on Barrett’s esophagus is still challenging and frequent matter of publications: one paper in this issue is very informative as it shows that when both magnified white light imaging and magnified NBImaging do not demonstrate any vascular or mucosal abnormalities, tissue analyzed does not contain any high grade dysplastic areas and theoretically does not need to be biopsied. But zoom is mandatory (and cumbersome) and the problem related to the diagnosis of low grade dysplasia is still not solved. Another interesting paper on Barrett’s esophagus evaluates a potential (and very trendy) application of confocal laser endomicroscopy (CLE): to delineate neoplastic lesions (in particular subsquamous carcinomatous extension) and to assist in real time endoscopic resection. Interestingly, three out of the 6 subsquamous extensions were only detected by CLE. Two papers are targeted on bleeding following endoscopic submucosal dissection (the role of aspirin and antiplatelet drugs and the influence of renal dysfunction). Although bleeding following ESD is not a major issue in comparison to perforation, its prevention still needs more evaluation. Two other papers are focused on esophageal stents. Esophageal stenting is a well established procedure but still needs some research, in particular concerning its interaction with radiation therapy (for example if a bridge-to-radiotherapy policy is promoted) or concerning the treatment of benign stenoses or fistulae. Whereas previous studies demonstrated that a metal esophageal stent causes dose perturbation during conventional photon therapy, the study presented in this issue observes that this is not the case with proton therapy, which aims at reducing radiation dose of surrounding tissues. Stent removal in case of benign stenosis is sometimes difficult for different reasons. It is reported in this issue of EIO that cooling a nitinol stent (by a spray of ice water) makes the stent more flexible with a smaller diameter and then could ease stent removal by the inversion technique. The role of EUS-guided celiac plexus block for chronic pancreatitis is debatted due to morbidity and temporary effects. The study published in this issue is the first one to evaluate the safety and effectiveness of repeated injections. Morbidity rate was low and pain relief rate was quite good (76 %), whereas the response rate to the first treatment was predictive of the effect of subsequent injections. This issue also includes the first tandem trial comparing 25-gauge histology needle versus 22-gauge cytology needle in EUS-guided sampling of pancreatic lesions and lymphadenopathy, with randomization of the order in which the needles were used. Colonic mucosal lesions can be observed in patients receiving oral sodium phosphate (NaP) as bowel cleansing. They are benign and non specific. Gastric mucosal injuries are also observed following NaP tablet cleansing when upper gastrointestinal endoscopy is associated to colonoscopy. These lesions are usually asymptomatic but it was mandatory to conduct an experimental study to demonstrate their reversibility. Interval cancers can be related to incomplete polyp removal during colonoscopy. We still need to define which should be the recommended method to remove diminutive polyps: cold biopsy, hot biopsy, cold snare or hot snare? A pilot study was conducted to see if the question is relevant for all techiques and to set the optimal design for a large muticenter trial: 1 in 10 diminutive polyps were incompletely resected. Many techniques to close gastrostomy during NOTES have been tested with variable success and for this reason and others, NOTES is still in stand-by. The experimental work presented here suggests that the combination of a submucosal tunnel and a closure by over-the-scope clip is effective and could help to revive NOTES in some applications. Finally, a retrospective analysis of a large series of post-cholecystectomy fistulae has been conducted. This paper emphasizes once again the role of MRCP and a management based on a precise analysis and classification of the lesions and on a multidisciplinary approach.

Thierry Ponchon, MD

Editor-in-Chief, Endoscopy International Open