Outcomes of Endoscopic Resection of Large Colorectal Neoplasms: An Australian Experience
Muna Salama; Donald Ormonde ; Thai Quach; Hooi Ee; Ian Yusoff

Abstract
Background and Aims: Endoscopic resection of large colorectal neoplasms is increasingly being used as an alternative to surgery. However data on failure rates, safety and long-term outcomes remain limited. The aim of the study was to report short- and long-term outcomes from endoscopic resection of large colorectal neoplasms from a single centre and use a model to predict mortality had surgery been performed.

Methods: Consecutive patients referred for endoscopic resection of large ( 20 mm) colorectal neoplasms from January 2001 to February 2008 were included. Resection details were recorded in a prospectively maintained database. Data was collected on 30-day complication rates, and follow-up colonoscopy findings. The Colorectal-POSSUM score was used to estimate mortality from open surgery .

Results: There were 154 large neoplasms in 140 patients. Mean age was 68 years (range 2294). Mean neoplasm size was 26 mm (range 2080 mm, 24 40 mm). Complete endoscopic removal was achieved in 95% of cases. Twenty patients were referred for surgery (14%). In the endoscopy group, there were no deaths within 30 days. Twelve patients had a complication including two perforations. Endoscopic follow-up data was available in 90% of cases and five patients (4%) were found to have residual adenomathat was treated endoscopically with subsequent clearance. If surgery had been performed, the mean predicted mortality was 2 .2% (range 0.5 10%). There were two deaths (10%) in patients who underwent elective surgery within 30 days.

Conclusion: Endoscopic resection of large colorectal neoplasms is safe and effective even for very large benign neoplasms. When the lesion is endoscopically resectable this should be the preferred treatment.

Introduction
Colonoscopic resection is being increasingly used as an alternative to surgery for the removal of large colorectal neoplasms. This approach has become standard practice, and has been enthusiastically embraced by gastroenterologists despite limited data being available regarding safety, failure rates and long-term outcomes. Reported neoplasm persistence rates vary widely between 0% and 60%, and reported complication rates ranging from 1 9%.[15] No randomized studies comparing colonoscopic resection with surgical techniques have been performed.

We aimed to study short- and long-term outcomes of endoscopic resection of large colorectal neoplasms in consecutive patients over 8 years in a single center. We then compared these outcomes with predicted mortality from open surgery using a previously validated model, Colorectal-POSSUM (CR-POSSUM) score .[69]

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Bugs and Irritable Bowel Syndrome: The Good, the Bad and the Ugly
Uday C Ghoshal ; Hyojin Park; Kok-Ann Gwee

Abstract
Recently, there has been strong interest in the therapeutic potential of probiotics for irritable bowel syndrome (IBS). At the same time, there is a rapidly growing body of evidence to support an etiological role for gastrointestinal infection and the associated immune activation in the development of post-infectious IBS. In a more controversial area, small intestinal bacterial overgrowth has been associated with a subset of patients with IBS; the issue of whether it is appropriate to treat a subset of IBS patients with antibiotics and probiotics is currently a matter for debate. Thus, it appears that the gastrointestinal microbial flora may exert beneficial effects for symptoms of IBS under some circumstances, while in other situations gut microbes could give rise to symptoms of IBS. How do we make sense of the apparently diverse roles that 'bugs' may play in IBS? To address this question, we have conducted an in-depth review, attempting where possible to draw lessons from Asian studies.

Introduction
The gut contains a vast and complex microbial ecosystem, comprising mainly bacteria, of which most are strict anaerobes; it also includes fungi and viruses.[1,2] The human gastrointestinal (GI) tract contains more than 500 1000 species of bacteria.[3] The bacterial population increases in number and diversity in the more distal parts of the gut; human large intestine contains as many as 10[11 12] organisms per gram of fecal material. [4] Recently, there has been increased interest in the role of qualitative and quantitative changes in gut flora in health and in GI diseases. Irritable bowel syndrome (IBS), a common gastrointestinal disorder of unknown pathogenesis, is one such condition which might be related to changes in the gut flora.

Recent published reports on post -infectious IBS (PI-IBS),[5] small intestinal bacterial overgrowth (SIBO) in IBS, [6] relationships between the gut flora and sensorimotor functions of the GI tract,[3] and the role of probiotics[7,8] and antibiotics[9] in altering the symptoms of IBS provide evidence supporting this issue. Food hygiene, the nature and frequency of GI infections and infestations and the composition of the gut flora areexpected to differ in some Asian countries compared with North America , Europe and Australia/New Zealand . Hence, we sought to review the relationship between gut flora, GI infections and IBS, with particular attention to the Asian published reports.

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Evidence-based Dietary Management of Functional Gastrointestinal Symptoms: The FODMAP Approach
Peter R Gibson ; Susan J Shepherd

Abstract
Background and aim: Functional gastrointestinal symptoms are common and their management is often a difficult clinical problem. The link between food intake and symptom induction is recognized. This review aims to describe the evidence base for restricting rapidly fermentable, short-chain carbohydrates (FODMAPs) in controlling such symptoms.

Methods: The nature of FODMAPs, their mode of action in symptom induction , results of clinical trials and the implementation of the diet are described.

Results: FODMAPs are widespread in the diet and comprise a monosaccharide (fructose), a disaccharide (lactose), oligosaccharides (fructans and galactans), and polyols. Their ingestion increases delivery of readily fermentable substrate and water to the distal small intestine and proximal colon, which are likely to induce luminal distension and induction of functional gut symptoms

The restriction of their intake globally (as opposed to individually) reduces functional gut symptoms, an effect that is durable and can be reversed by their reintroduction into the diet (as shown by a randomized placebo-controlled trial ). The diet has a high compliance rate. However it requires expert delivery by a dietitian trained in the diet. Breath hydrogen tests are useful to identify individuals who can completely absorb a load of fructose and lactose so that dietary restriction can be less stringent.

Conclusions: The low FODMAP diet provides an effective approach to the management of patients with functional gut symptoms. The evidence base is now sufficiently strong to recommend its widespread application .

Introduction
Functional gastrointestinal disorders (FGID) are very common and present as major challenges for clinicians, particularly as pharmaceutical therapies offer little more than mild palliation in the vast majority of patients. The symptoms can markedly interfere with quality of life and rank second in the causes of absence from work or school.[1] While the predominant underlying cause of symptoms appears to reside in the enteric nervous system, manifesting as visceral hypersensitivity and/or motility disturbances, multiple other factors contribute to symptoms generation, including psychological factors and diet. Consequently, treatment has spanned multiple modalities and has involved a variety of health professionals, including medical practitioners, psychologists, hypnotherapists, dietitians and naturopaths, each bringing a different perspective.

A major limitation has been the limited evidence base for many therapies , not helped by the considerable placebo response seen in these disorders. However, dietary therapy, specifically the low FODMAP diet (see below for explanation), has now emerged as a key player with a well-substantiated mechanism of action and evidence-based efficacy. This review will describe the theoretical basis for the diet, the evidence for efficacy and its implementation, and it will address unanswered questions.

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Can Wire-guided Cannulation Reduce the Risk of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis? AMeta-analysis of Randomized Controlled Trials Can Wire-Guided
Cannulation Reduce the Risk
Li-Ming Shao; Qing-Yu Chen; Miao-Yan Chen; Jian -Ting Cai

Abstract
Background and Aim: The use of wire-guided cannulation (WGC) for prevention of post -endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is controversial. The aim of the present study was to assess the overall effect of WGC for PEP compared with conventional contrast-assisted cannulation by carrying out a meta-analysis of all available randomized controlled trials (RCT).

Methods: Electronic databases, including PubMed, EMBASE, the Cochrane library and the Science Citation Index, were searched to retrieve relevant trials . In addition, meeting abstracts and the reference lists of retrieved articles were reviewed for further relevantstudies. Outcome measures were the incidence of PEP.

Results: Four RCT, enrolling a total of 1413 patients, were included. The meta-analysis failed to indicate a significant association between the use of WGC and the reduction of PEP (RR 0 .34; 95% CI: 0 .10 1.17; P = 0.09). Subgroup analysis including trials without cross-over design showed a significant benefit with the use of WGC in reducing PEP (RR 0.20; 95% CI: 0.090.40; P P = 0.58).

Conclusions: This meta-analysis showed only a non-significant reduction in the rate of PEP with the use of WGC. Further well-designed RCT are required to confirm the effect of WGC, especially in patients who were easier to cannulate.

Introduction
Acute pancreatitis remains the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). The incidence of post-ERCP pancreatitis (PEP) varies from 1% to 40% partly as a result of the definition of PEP,[1] but figures of 1.3% to 6.7% are typical in large prospective studies. [26] Generally, ways to prevent of PEP can be divided into two categories: pharmacological and mechanical. However, pharmacological prevention has not been proved effective, although rectal non steroidal anti-inflammatory drugs (NSAIDs) were reported to be efficacious in a recent meta-analysis.[7] Furthermore, no pharmacological agents are widely used in routine clinical practice. Pancreatic duct (PD) stent placement and wire-guided cannulation (WGC) are the most two common endoscopic techniques used in reducing PEP.[8] The prophylactic use of PD stent in patients at high risk has become standard of care,[710 ] whereas the use of WGC for PEP has not reached a consensus by endoscopists.[1114 ]

Accessing the bile duct with the aid of a guidewire may limit mechanical trauma to the papilla or pancreatic sphincter and avoid hydrostatic pressure associated with contrast injection, thereby reducing the likelihood of PEP.[12,13] Recently, several randomized controlled trials (RCT) have been conducted to evaluate the effect of WGC in the prevention of PEP.[1214 ] However, these studies have yielded conflicting conclusions. Therefore, we thought it worthwhile to conduct a metaanalysis of all available RCT to assess the overall effect of WGC for PEP.

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Effect of Laparoscopic Splenectomy on Portal Hypertensive Gastropathy in Cirrhotic Patients With Portal Hypertension
Effect of Laparoscopic Splenectomy and Portal Hypertensive Gastropathy
Go Anegawa ; Hirofumi Kawanaka; Hideo Uehara; Tomohiko Akahoshi; Kozo Konishi ; Daisuke Yoshida ; Nao Kinjo; Naotaka Hashimoto; Morimasa Tomikawa; Makoto

Hashizume; Yoshihiko Maehara

Abstract
Aim: This study investigated the relationship between portal hypertensive gastropathy (PHG) and splenomegaly, and the effect of laparoscopic splenectomy on PHG in cirrhotic patients with portal hypertension.

Methods: Seventy patients with liver cirrhosis and portal hypertension were prospectively studied . Indication for laparoscopic splenectomy was bleeding tendency in 10 patients, induction of interferon in 45, treatment of hepatocellular carcinoma in seven, and treatment for endoscopic injection sclerotherapy-resistant esophagogastric varices in eight. The severity of PHG was classified into none, mild, or severe according to the classification by McCormack et al. The severity of liver disease was classified using the Child-Pugh score. All patients underwent upper gastrointestinal endoscopy before and 1 month after the operation.

Results: The prevalence of PHG was significantly correlated with the severity of liver disease using the Child-Pugh score . The severity of PHG was significantly correlated with the resected spleen volume. One month after the operation, PHG was improved in 16 of 17 patients with severe PHG and in 12 of 32 with mild PHG. The Child-Pugh score showed a significant improvement (6.8 ± 1.4 to 6 .2 ± 1 .2) at 3 months after laparoscopic splenectomy.

Conclusions: PHG may be associated with splenomegaly, and laparoscopic splenectomy may have a beneficial effect on PHG, at least for a short time.

Introduction
Portal hypertensive gastropathy (PHG) is an endoscopic abnormality of the gastric mucosa that is most commonly observed in patients with advanced liver disease and/or portal hypertension.[1,2] Since the report of McCormack et al. in 1985, the occurrence of these gastric mucosal lesions has been termed congestive gastropathy or PHG.[3] This endoscopic lesion is characterized by the presence of a mucosal mosaic pattern with a snakeskin-like appearance, focal red and brown spots, and vascular ectasia localized in the fundus or body of the stomach .[4] It involves macroscopic changes in the gastric mucosa that occur in portal hypertension, which are associated with mucosal and submucosal vascular dilatation and ectasia without significant inflammatory changes.[3]

Recently, PHG has emerged as a new nosological entity that can be included among the complications of liver cirrhosis, regardless of the low incidence of acute bleeding from PHG.[2,5] Previous reports have shown that the frequency of bleeding was higher in those with severe PHG (38-62%) compared with mild PHG (3 .5-31%), [5,6] and a non-selective ß-blocker , such as propranolol , is an effective therapy for PHG.[7-9] Portosystemic shunt surgery effectively reduces portal venous pressure and it has been shown to be useful in the treatment of bleeding from PHG.[10 ] Nonetheless, there are inevitable operative risks in treating advanced liver disease. Recently, a few reports have shown the effect of a transjugular intrahepatic portosystemic shunt (TIPS) on PHG,[11,12] however, there are some complications with portosystemic encephalopathy and shunt dysfunction. In this study, we aimed to determine : (i) whether splenomegaly is associated with PHG in cirrhotic patients; and (ii) if laparoscopic splenectomy influences the endoscopic findings of PHG.

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Comparsion of Selected Sedation Scales for Reporting Opioid Induced Sedation Assessment
Allison Theresa Nisbet , MSN, CPN, AOCNS, RN-BC; Florence Mooney-Cotter , MSN, CNS-BC, RN-BC

Abstract
A descriptive survey-based study was undertaken to test the validity and reliability of three scales that are used to assess sedation during opioid administration for pain management : the Inova Health System Sedation Scale (ISS), the Richmond Agitation and Sedation Scale (RASS), and the Pasero Opioid-Induced Sedation Scale (POSS). The study was conducted in a large (830 beds) suburban level I trauma hospital with a random convenience sample of 96 medical-surgical nurses. The study reports: measures of reliability and validity of each scale and significant findings related to correct nursing score and selected actions; nurses' ratings of each scale in terms of combined ease of use; information provided by the scale to inform clinical decisions; and nursing confidence measures.

Both the RASS and the POSS demonstrated adequate measures of reliability and validity for measurement of sedation during opioid administration for pain management . However, the POSS scored higher in combined measures of ease of use, nursing confidence, and usefulness of information provided to make clinical decisions. The POSS also yielded the highest percentage agreement with the correct score and correct nursing actions chosen by the nurse among the three scales tested. Study results have clinical significance for accuracy of clinical assessments andsubsequent actions on behalf of patients experiencing advancing sedation during opioid analgesia. The POSS can be recommended as a superior sedation scale for the measurement of sedation during opioid administration for pain management.

Introduction
Opioid-induced sedation represents a continuum of levels of consciousness and arousability ideally measured by reliable and valid criteria that are applied in clinical practice for safe and effective administration of opioid analgesics (American Society for Pain Management Nursing [ASPMN] , 2009). Opioid-induced respiratory depression is a concerning decrease in the effectiveness of an individual's ventilatory function after opioid administration (ASPMN, 2009).
For the purposes of this study, sedation is recognized as a relatively common side effect of opioid analgesia (Pasero & McCaffery , 2002; Szalados & Boysen, 1998), and advancing sedation has been identified as a precedent to clinically significant respiratory depression (Pasero & McCaffery, 2002). As such, nurses should systematically assess and document in the medical record the incidence and severity of sedation during opioid administration for pain management.

Furthermore, the assessment should lead the nurse to make appropriate decisions about how to proceed with opioid administration. Although sedation occurs on a continuum, it does not correlate directly with laboratory values of opioid drug levels (Szalados & Boysen, 1998). As a result, sedation, much like pain, must be serially assessed to identify discrete levels at any given moment in time and to identify incremental changes in direction of sedation level (increasing or decreasing). The incidence and severity of opioid-induced sedation is influenced by many factors, including whether the patient is opioid tolerant (taking regular daily doses of opioids for several days) or opioid naive (Pasero & McCaffery, 2002), concurrent administration of other sedating medications (such as benzodiazepines) (Szalados & Boysen, 1998), and the patient's general health and clinical condition (Smith, 2007).

Patients at extremes of age (the very young and the very old ), with end-organ damage affecting opioid metabolism and elimination, with obstructive sleep apnea (diagnosed or not ), and with baseline alterations in respiratory or neurological function are at a higher risk for increased sedation and subsequent respiratory depression as a complication of opioid therapy (Pasero & McCaffery, 2002; Smith, 2007). In addition, some pain management therapies , including intermittent intramuscular, intravenous, or subcutaneous opioid injections, intravenous patient- controlled analgesia (IV PCA), and intraspinal pain management , may increase the risk of sedation.

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