Clinical Focus

  • Endoscopy
  • Gastroenterology

Academic Appointments

Professional Education

  • Medical Education:UCSD School of Medicine (1996) CA
  • Fellowship:Stanford University School of Medicine (2002) CA
  • Residency:Stanford University School of Medicine (1999) CA
  • Internship:Stanford University School of Medicine (1997) CA
  • Board Certification: Gastroenterology, American Board of Internal Medicine (2002)
  • Board Certification: Internal Medicine, American Board of Internal Medicine (1999)

Research & Scholarship

Current Research and Scholarly Interests

1. Gastrointestinal Endoscopy- Techniques and Outcomes
2. Development of new endoscopic devices
3. Diagnosis of intestinal ischemia
4. High risk endoscopic resection

Clinical Trials

  • Advanced Gastrointestinal Endoscopic Imaging Not Recruiting

    To develop new methods to detect malignant and premalignant conditions of the gastrointestinal tract.

    Stanford is currently not accepting patients for this trial. For more information, please contact Chirstopher Contag, (650) 725 - 8781.

    View full details


2015-16 Courses


All Publications

  • Cyst Fluid Glucose is Rapidly Feasible and Accurate in Diagnosing Mucinous Pancreatic Cysts AMERICAN JOURNAL OF GASTROENTEROLOGY Zikos, T., Pham, K., Bowen, R., Chen, A. M., Banerjee, S., Friedland, S., Dua, M. M., Norton, J. A., Poultsides, G. A., Visser, B. C., Park, W. G. 2015; 110 (6): 909-914


    Better diagnostic tools are needed to differentiate pancreatic cyst subtypes. A previous metabolomic study showed cyst fluid glucose as a potential marker to differentiate mucinous from non-mucinous pancreatic cysts. This study seeks to validate these earlier findings using a standard laboratory glucose assay, a glucometer, and a glucose reagent strip.Using an IRB-approved prospectively collected bio-repository, 65 pancreatic cyst fluid samples (42 mucinous and 23 non-mucinous) with histological correlation were analyzed.Median laboratory glucose, glucometer glucose, and percent reagent strip positive were lower in mucinous vs. non-mucinous cysts (P<0.0001 for all comparisons). Laboratory glucose<50 mg/dl had a sensitivity of 95% and a specificity of 57% (LR+ 2.19, LR- 0.08). Glucometer glucose<50 mg/dl had a sensitivity of 88% and a specificity of 78% (LR+ 4.05, LR- 0.15). Reagent strip glucose had a sensitivity of 81% and a specificity of 74% (LR+ 3.10, LR- 0.26). CEA had a sensitivity of 77% and a specificity of 83% (LR+ 4.67, LR- 0.27). The combination of having either a glucometer glucose<50 mg/dl or a CEA level>192 had a sensitivity of 100% but a low specificity of 33% (LR+ 1.50, LR- 0.00).Glucose, whether measured by a laboratory assay, a glucometer, or a reagent strip, is significantly lower in mucinous cysts compared with non-mucinous pancreatic cysts.

    View details for DOI 10.1038/ajg.2015.148

    View details for Web of Science ID 000357081800020

  • Predictive Factors for Surgery Among Patients with Pancreatic Cysts in the Absence of High-Risk Features for Malignancy JOURNAL OF GASTROINTESTINAL SURGERY Quan, S. Y., Visser, B. C., Poultsides, G. A., Norton, J. A., Chen, A. M., Banerjee, S., Friedland, S., Park, W. G. 2015; 19 (6): 1101-1105


    Without a reliable biopsy technique for pancreatic cysts, consensus-based guidelines are used to guide surgical utilization. The primary objective of this study was to characterize the proportion of operations performed outside of these guidelines.A 5-year retrospective review between July 1, 2007, and June 30, 2012, was performed of consecutive patients seen at a single tertiary medical center for a pancreatic cyst. Manual chart review for relevant clinical variables and cyst characteristics was performed.During this period, 148 patients underwent surgery, and of these, 23 (16 %) patients had no high-risk criteria by the 2006 Sendai criteria. None of these harbored high-grade dysplastic or cancerous lesions. A high cyst carcinoembryonic antigen (CEA) level (35 %), patient anxiety (26 %), and physician concern (22 %) were explicit reasons to proceed to surgery. An elevated cyst CEA level >192 ng/ml was the most significant predictor (OR 5.14 (95 % confidence interval (CI) 1.47-18.0) for surgery without high-risk criteria.A high cyst CEA level was significantly associated with the decision to operate outside of consensus-based guidelines. The misuse of cyst CEA in the management of pancreatic cysts negatively impacts patient anxiety, increases physician uncertainty, and leads to surgery with minimal benefit.

    View details for DOI 10.1007/s11605-015-2786-3

    View details for Web of Science ID 000355344300016

    View details for PubMedID 25749855

  • A Real-Time Clinical Endoscopic System for Intraluminal, Multiplexed Imaging of Surface-Enhanced Raman Scattering Nanoparticles PLOS ONE Garai, E., Sensarn, S., Zavaleta, C. L., Loewke, N. O., Rogalla, S., Mandella, M. J., Felt, S. A., Friedland, S., Liu, J. T., Gambhir, S. S., Contag, C. H. 2015; 10 (4)
  • Radiation exposure to patients during ERCP is significantly higher with low-volume endoscopists. Gastrointestinal endoscopy Liao, C., Thosani, N., Kothari, S., Friedland, S., Chen, A., Banerjee, S. 2015; 81 (2): 391-8 e1


    Patients are exposed to radiation during ERCP, and this may increase their lifetime risk of the development of cancer and other deleterious radiation effects.To evaluate the association between the endoscopist's ERCP volume and the patient radiation dose during ERCP.Single-center, retrospective study.Tertiary referral center.A total of 197 patients undergoing 331 ERCPs.Patient radiation exposure parameters including fluoroscopy time, total radiation dose, dose area product, and effective dose for all ERCPs performed at our academic medical center by 2 high-volume endoscopists (HVEs) (≥200 ERCPs/year) and 7 low-volume endoscopists (LVEs). Radiation exposure for each ERCP was adjusted against a validated procedure complexity scale and the Stanford Fluoroscopy Complexity Score, which was created based on the numbers of interventions that would mandate additional radiation exposure.ERCPs performed by LVEs were associated with a significantly higher median total radiation dose (98.30 mGy vs 74.13 mGy), dose area product (13.98 Gy-cm(2) vs 8.8 Gy-cm(2)), and effective dose (3.63 mSv vs 2.28 mSv), despite lower median Stanford Fluoroscopy Complexity Scores (3.0 vs 6.0) compared with HVEs. No significant difference was noted in median fluoroscopy time (4.0 minutes vs 3.30 minutes) between LVEs and HVEs.Retrospective, single-center study at a tertiary referral center.ERCPs performed by LVEs are associated with significantly higher radiation exposure to patients compared with those performed by HVEs despite the fact that procedures performed by HVEs are of greater complexity.

    View details for DOI 10.1016/j.gie.2014.08.001

    View details for PubMedID 25293825

  • Radiation exposure to patients during ERCP is significantly higher with low-volume endoscopists GASTROINTESTINAL ENDOSCOPY Liao, C., Thosani, N., Kothari, S., Friedland, S., Chen, A., Banerjee, S. 2015; 81 (2): 391-U453
  • Short turn radius colonoscope in an anatomical model: Retroflexed withdrawal and detection of hidden polyps WORLD JOURNAL OF GASTROENTEROLOGY Mcgill, S. K., Kothari, S., Friedland, S., Chen, A., Park, W. G., Banerjee, S. 2015; 21 (2): 593-599


    To evaluate the new RetroView™ colonoscope and compare its ability to detect simulated polyps "hidden" behind colonic folds with that of a conventional colonoscope, utilizing anatomic colon models.Three anatomic colon models were prepared, with twelve simulated polyps "hidden" behind haustral folds and five placed in easily viewed locations in each model. Five blinded endoscopists examined two colon models in random order with the conventional or RetroView™ colonoscope, utilizing standard withdrawal technique. The third colon model was then examined with the RetroView™ colonoscope withdrawn initially in retroflexion and then in standard withdrawal. Polyp detection rates during standard and retroflexed withdrawal of the conventional and RetroView™ colonoscopes were determined. Polyp detection rates for combined standard and retroflexed withdrawal (combination withdrawal) with the RetroView™ colonoscope were also determined.For hidden polyps, retroflexed withdrawal using the RetroView™ colonoscope detected more polyps than the conventional colonoscope in standard withdrawal (85% vs 12%, P = 0.0001). For hidden polyps, combination withdrawal with the RetroView™ colonoscope detected more polyps than the conventional colonoscope in standard withdrawal (93% vs 12%, P ≤ 0.0001). The RetroView™ colonoscope in "combination withdrawal" was superior to other methods in detecting all (hidden + easily visible) polyps, with successful detection of 80 of 85 polyps (94%) compared to 28 (32%) polyps detected by the conventional colonoscope in standard withdrawal (P < 0.0001) and 67 (79%) polyps detected by the RetroView™ colonoscope in retroflexed withdrawal alone (P < 0.01). Continuous withdrawal of the colonoscope through the colon model while retroflexed was achieved by all endoscopists. In a post-test survey, four out of five colonoscopists reported that manipulation of the colonoscope was easy or very easy.In simulated testing, the RetroView™ colonoscope increased detection of hidden polyps. Combining standard withdrawal with retroflexed withdrawal may become the new paradigm for "complete screening colonoscopy".

    View details for DOI 10.3748/wjg.v21.i2.593

    View details for Web of Science ID 000348419200025

    View details for PubMedID 25593483

  • Effect of prior biopsy sampling, tattoo placement, and snare sampling on endoscopic resection of large nonpedunculated colorectal lesions GASTROINTESTINAL ENDOSCOPY Kim, H. G., Thosani, N., Banerjee, S., Chen, A., Friedland, S. 2015; 81 (1): 204-213


    Endoscopic manipulations, including biopsy sampling, tattoo application on the lesion itself, and sampling of the lesion with a polypectomy snare, are frequently performed on large nonpedunculated colorectal lesions ≥ 20 mm (LNCL) before referral for endoscopic resection.To assess the effect of prior manipulations on the technical difficulty and recurrence rates of subsequent endoscopic treatment.Retrospective study.Two referral centers.Patients with LNCL referred for endoscopic resection.Endoscopic resection.En-bloc resection rate, rate of successful complete endoscopic resection without the need for ablation of visible residual, recurrence rate on follow-up, independent predictive factors for en-bloc resection, complete resection without ablation of visible residual, and recurrence.A total of 132 lesions was analyzed: 46 lesions without any prior manipulation, 44 with prior biopsy sampling only, and 42 with prior advanced manipulation including tattoo and/or snare sampling. The en-bloc resection rate was 34.8% for nonmanipulated lesions, 15.9% for lesions with prior biopsy sampling, and 4.8% for lesions with prior advanced manipulation (P = .001). Complete endoscopic resection without the need for ablation of visible residual was performed in 93.5% of nonmanipulated lesions, 68.2% of lesions with prior biopsy sampling, and 50% of lesions with prior advanced manipulation (P < .001). Recurrence rates were 7.7%, 40.7%, and 53.8% in the 3 groups (P = .001). In multivariate analysis, prior biopsy sampling was an independent predictor for inability to perform complete resection without ablation of visible residual (odds ratio .24, P < .05) and for recurrence (odds ratio 11.5, P = .004) compared with nonmanipulated lesions. Prior advanced manipulation was an independent predictor for inability to perform en-bloc resection (odds ratio .024, P = .001), for inability to perform complete resection without ablation of visible residual (odds ratio .081, P < .001), and for recurrence (odds ratio 18.8, P = .001).Retrospective study.Prior biopsy sampling and advanced manipulation have significant deleterious effects on endoscopic treatment of LNCL.

    View details for DOI 10.1016/j.gie.2014.08.038

    View details for Web of Science ID 000346442900024

  • The learning curve for detection of non-polypoid (flat and depressed) colorectal neoplasms. Gut Mcgill, S. K., Kaltenbach, T., Friedland, S., Soetikno, R. 2015; 64 (1): 184-185

    View details for DOI 10.1136/gutjnl-2013-305743

    View details for PubMedID 23946382

  • A real-time clinical endoscopic system for intraluminal, multiplexed imaging of surface-enhanced Raman scattering nanoparticles. PloS one Garai, E., Sensarn, S., Zavaleta, C. L., Loewke, N. O., Rogalla, S., Mandella, M. J., Felt, S. A., Friedland, S., Liu, J. T., Gambhir, S. S., Contag, C. H. 2015; 10 (4)


    The detection of biomarker-targeting surface-enhanced Raman scattering (SERS) nanoparticles (NPs) in the human gastrointestinal tract has the potential to improve early cancer detection; however, a clinically relevant device with rapid Raman-imaging capability has not been described. Here we report the design and in vivo demonstration of a miniature, non-contact, opto-electro-mechanical Raman device as an accessory to clinical endoscopes that can provide multiplexed molecular data via a panel of SERS NPs. This device enables rapid circumferential scanning of topologically complex luminal surfaces of hollow organs (e.g., colon and esophagus) and produces quantitative images of the relative concentrations of SERS NPs that are present. Human and swine studies have demonstrated the speed and simplicity of this technique. This approach also offers unparalleled multiplexing capabilities by simultaneously detecting the unique spectral fingerprints of multiple SERS NPs. Therefore, this new screening strategy has the potential to improve diagnosis and to guide therapy by enabling sensitive quantitative molecular detection of small and otherwise hard-to-detect lesions in the context of white-light endoscopy.

    View details for DOI 10.1371/journal.pone.0123185

    View details for PubMedID 25923788

  • Underwater endoscopic mucosal resection for recurrences after previous piecemeal resection of colorectal polyps GASTROINTESTINAL ENDOSCOPY Kim, H. G., Thosani, N., Banerjee, S., Chen, A., Friedland, S. 2014; 80 (6): 1094-1102


    Conventional endoscopic treatment of a recurrent adenoma after piecemeal EMR (PEMR) of a colorectal laterally spreading tumor (LST) is technically difficult with low en bloc resection rates because of the inability to snare fibrotic residual.To assess the feasibility of salvage underwater EMR (UEMR) for the treatment of recurrent adenoma after PEMR of a colorectal LST.Retrospective, cross-sectional study.Single, tertiary-care referral center.Patients who have recurrent adenoma after PEMR of colorectal LST (≥2 cm).UEMR versus EMR.En bloc resection rate, endoscopic complete removal rate, recurrence rate on follow-up colonoscopy, adjunctive ablation rate with argon plasma coagulation (APC) during salvage procedure, and independent predictive factors for successful en bloc resection and endoscopic complete removal.Eighty salvage procedures (36 UEMRs vs 44 EMRs) were analyzed. En bloc resection rate (47.2% vs 15.9%, P = .002) and endoscopic complete removal rate (88.9% vs 31.8%, P < .001) were higher in the UEMR group than in the EMR group. APC ablation of visible residual during salvage procedure was lower in UEMR group than EMR group (11.1% vs 65.9%, P < .001). Recurrence rate on follow-up colonoscopy was significantly lower in the UEMR group than the EMR group (10% vs 39.4%, P = .02). UEMR was an independent predictor of successful en bloc resection and endoscopic complete removal.Retrospective, single-center study.UEMR can be a useful and feasible technique as a salvage procedure for recurrent colorectal adenoma after PEMR.

    View details for DOI 10.1016/j.gie.2014.05.318

    View details for Web of Science ID 000346441600021

  • Outcomes of repeat colonoscopy in patients with polyps referred for surgery without biopsy-proven cancer GASTROINTESTINAL ENDOSCOPY Friedland, S., Banerjee, S., Kochar, R., Chen, A., Shelton, A. 2014; 79 (1): 101-107


    Despite advances in endoscopic treatment, many colonic adenomas are still referred for surgical resection. There is a paucity of data on the suitability of these lesions for endoscopic treatment.To analyze the results of routine repeat colonoscopy in patients referred for surgical resection of colon polyps without biopsy-proven cancer.Retrospective review.University hospital.Patients referred to a colorectal surgeon for surgical resection of a polyp without biopsy-proven cancer.Repeat colonoscopy.The rate of successful endoscopic treatment.There were 38 lesions in 36 patients; 71% of the lesions were noncancerous and were successfully treated endoscopically. In 26% of the lesions, previous removal was attempted by the referring physician but was unsuccessful. The adenoma recurrence rate was 50%, but all recurrences were treated endoscopically and none were cancerous. Two patients were admitted for overnight observation. There were no major adverse events.Single center, retrospective.In the absence of biopsy-proven invasive cancer, it is appropriate to reevaluate patients referred for surgical resection by repeat colonoscopy at an expert center.

    View details for DOI 10.1016/j.gie.2013.06.034

    View details for Web of Science ID 000328736700018

    View details for PubMedID 23916398

  • Treatment of nonampullary sporadic duodenal adenomas with endoscopic mucosal resection or ablation. Digestive diseases and sciences Perumpail, R., Friedland, S. 2013; 58 (10): 2751-2752

    View details for DOI 10.1007/s10620-013-2787-6

    View details for PubMedID 23884756

  • Metabolomic-derived novel cyst fluid biomarkers for pancreatic cysts: glucose and kynurenine. Gastrointestinal endoscopy Park, W. G., Wu, M., Bowen, R., Zheng, M., Fitch, W. L., Pai, R. K., Wodziak, D., Visser, B. C., Poultsides, G. A., Norton, J. A., Banerjee, S., Chen, A. M., Friedland, S., Scott, B. A., Pasricha, P. J., Lowe, A. W., Peltz, G. 2013; 78 (2): 295-302 e2


    BACKGROUND: Better pancreatic cyst fluid biomarkers are needed. OBJECTIVE: To determine whether metabolomic profiling of pancreatic cyst fluid would yield clinically useful cyst fluid biomarkers. DESIGN: Retrospective study. SETTING: Tertiary-care referral center. PATIENTS: Two independent cohorts of patients (n = 26 and n = 19) with histologically defined pancreatic cysts. INTERVENTION: Exploratory analysis for differentially expressed metabolites between (1) nonmucinous and mucinous cysts and (2) malignant and premalignant cysts was performed in the first cohort. With the second cohort, a validation analysis of promising identified metabolites was performed. MAIN OUTCOME MEASUREMENTS: Identification of differentially expressed metabolites between clinically relevant cyst categories and their diagnostic performance (receiver operating characteristic [ROC] curve). RESULTS: Two metabolites had diagnostic significance-glucose and kynurenine. Metabolomic abundances for both were significantly lower in mucinous cysts compared with nonmucinous cysts in both cohorts (glucose first cohort P = .002, validation P = .006; and kynurenine first cohort P = .002, validation P = .002). The ROC curve for glucose was 0.92 (95% confidence interval [CI], 0.81-1.00) and 0.88 (95% CI, 0.72-1.00) in the first and validation cohorts, respectively. The ROC for kynurenine was 0.94 (95% CI, 0.81-1.00) and 0.92 (95% CI, 0.76-1.00) in the first and validation cohorts, respectively. Neither could differentiate premalignant from malignant cysts. Glucose and kynurenine levels were significantly elevated for serous cystadenomas in both cohorts. LIMITATIONS: Small sample sizes. CONCLUSION: Metabolomic profiling identified glucose and kynurenine to have potential clinical utility for differentiating mucinous from nonmucinous pancreatic cysts. These markers also may diagnose serous cystadenomas.

    View details for DOI 10.1016/j.gie.2013.02.037

    View details for PubMedID 23566642

  • Metabolomic-derived novel cyst fluid biomarkers for pancreatic cysts: glucose and kynurenine GASTROINTESTINAL ENDOSCOPY Park, W. G., Wu, M., Bowen, R., Zheng, M., Fitch, W. L., Pai, R. K., Wodziak, D., Visser, B. C., Poultsides, G. A., Norton, J. A., Banerjee, S., Chen, A. M., Friedland, S., Scott, B. A., Pasricha, P. J., Lowe, A. W., Peltz, G. 2013; 78 (2): 295-?
  • A Raman-based endoscopic strategy for multiplexed molecular imaging. Proceedings of the National Academy of Sciences of the United States of America Zavaleta, C. L., Garai, E., Liu, J. T., Sensarn, S., Mandella, M. J., Van de Sompel, D., Friedland, S., Van Dam, J., Contag, C. H., Gambhir, S. S. 2013; 110 (25): E2288-97


    Endoscopic imaging is an invaluable diagnostic tool allowing minimally invasive access to tissues deep within the body. It has played a key role in screening colon cancer and is credited with preventing deaths through the detection and removal of precancerous polyps. However, conventional white-light endoscopy offers physicians structural information without the biochemical information that would be advantageous for early detection and is essential for molecular typing. To address this unmet need, we have developed a unique accessory, noncontact, fiber optic-based Raman spectroscopy device that has the potential to provide real-time, multiplexed functional information during routine endoscopy. This device is ideally suited for detection of functionalized surface-enhanced Raman scattering (SERS) nanoparticles as molecular imaging contrast agents. This device was designed for insertion through a clinical endoscope and has the potential to detect and quantify the presence of a multiplexed panel of tumor-targeting SERS nanoparticles. Characterization of the Raman instrument was performed with SERS particles on excised human tissue samples, and it has shown unsurpassed sensitivity and multiplexing capabilities, detecting 326-fM concentrations of SERS nanoparticles and unmixing 10 variations of colocalized SERS nanoparticles. Another unique feature of our noncontact Raman endoscope is that it has been designed for efficient use over a wide range of working distances from 1 to 10 mm. This is necessary to accommodate for imperfect centering during endoscopy and the nonuniform surface topology of human tissue. Using this endoscope as a key part of a multiplexed detection approach could allow endoscopists to distinguish between normal and precancerous tissues rapidly and to identify flat lesions that are otherwise missed.

    View details for DOI 10.1073/pnas.1211309110

    View details for PubMedID 23703909

  • A Raman-based endoscopic strategy for multiplexed molecular imaging PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA Zavaleta, C. L., Garai, E., Liu, J. T., Sensarn, S., Mandella, M. J., Van de Sompel, D., Friedland, S., Van Dam, J., Contag, C. H., Gambhir, S. S. 2013; 110 (25): E2288-E2297
  • Endoscopic management of nonlifting colon polyps. Diagnostic and therapeutic endoscopy Friedland, S., Shelton, A., Kothari, S., Kochar, R., Chen, A., Banerjee, S. 2013; 2013: 412936-?


    Background and Study Aims. The nonlifting polyp sign of invasive colon cancer is considered highly sensitive and specific for cancer extending beyond the mid-submucosa. However, prior interventions can cause adenomas to become nonlifting due to fibrosis. It is unclear whether nonlifting adenomas can be successfully treated endoscopically. The aim of this study was to evaluate outcomes in a referral practice incorporating a standardized protocol of attempted endoscopic resection of nonlifting lesions previously treated by biopsy, polypectomy, surgery, or tattoo placement. Patients and Methods. Retrospective review of patients undergoing colonoscopy by one endoscopist at two hospitals found to have nonlifting lesions from prior interventions. Lesions with biopsy proven invasive cancer or definite endoscopic features of invasive cancer were excluded. Lesions ? 8?mm were routinely injected with saline prior to attempted endoscopic resection. Polypectomy was performed using a stiff snare, followed by argon plasma coagulation (APC) if necessary. Results. 26 patients each had a single nonlifting lesion with a history of prior intervention. Endoscopic resection was completed in 25 (96%). 22 required snare resection and APC. 1 patient had invasive cancer and was referred for surgery. The recurrence rate on follow-up colonoscopy was 26%. All of the recurrences were successfully treated endoscopically. There was 1 postprocedure bleed (4%), no perforations, and no other complications. Conclusions. The majority of adenomas that are nonlifting after prior interventions can be treated successfully and safely by a combination of piecemeal polypectomy and ablation. Although recurrence rates are high at 26%, these too can be successfully treated endoscopically.

    View details for DOI 10.1155/2013/412936

    View details for PubMedID 23761952

  • Diagnostic Utility of Metabolomic-Derived Biomarkers for Pancreatic Cysts Park, W. G., Wu, M., Bowen, R., Zheng, M., Fitch, W. L., Pai, R. K., Wodziak, D., Visser, B. C., Poultsides, G. A., NORTON, J. A., Banerjee, S., Chen, A. M., Friedland, S., Pasricha, P. J., Lowe, A. W., Peltz, G. LIPPINCOTT WILLIAMS & WILKINS. 2012: 1394-1394
  • Water-aided colonoscopy: a systematic review GASTROINTESTINAL ENDOSCOPY Leung, F. W., Amato, A., Ell, C., Friedland, S., Harker, J. O., Hsieh, Y., Leung, J. W., Mann, S. K., Paggi, S., Pohl, J., Radaelli, F., Ramirez, F. C., Siao-Salera, R., Terruzzi, V. 2012; 76 (3): 657-666


    Water-aided methods for colonoscopy are distinguished by the timing of removal of infused water, predominantly during withdrawal (water immersion) or during insertion (water exchange).To discuss the impact of these approaches on colonoscopy pain and adenoma detection rate (ADR).Systematic review.Randomized, controlled trial (RCT) that compared water-aided methods and air insufflation during colonoscope insertion.Patients undergoing colonoscopy.Medline, PubMed, and Google searches (January 2008-December 2011) and personal communications of manuscripts in press were considered to identify appropriate RCTs.Pain during colonoscopy and ADR. RCTs were grouped according to whether water immersion or water exchange was used. Reported pain scores and ADR were tabulated based on group assignment.Pain during colonoscopy is significantly reduced by both water immersion and water exchange compared with traditional air insufflation. The reduction in pain scores was qualitatively greater with water exchange as compared with water immersion. A mixed pattern of increases and decreases in ADR was observed with water immersion. A higher ADR, especially proximal to the splenic flexure, was obtained when water exchange was implemented.Differences in the reports limit application of meta-analysis. The inability to blind the colonoscopists exposed the observations to uncertain bias.Compared with air insufflation, both water immersion and water exchange significantly reduce colonoscopy pain. Water exchange may be superior to water immersion in minimizing colonoscopy discomfort and in increasing ADR. A head-to-head comparison of these 3 approaches is required.

    View details for DOI 10.1016/j.gie.2012.04.467

    View details for Web of Science ID 000307948600028

    View details for PubMedID 22898423

  • Endoscopic mucosal resection with an over-the-counter hyaluronate preparation GASTROINTESTINAL ENDOSCOPY Friedland, S., Kothari, S., Chen, A., Park, W., Banerjee, S. 2012; 75 (5): 1040-1044


    Hyaluronic acid (HA) provides a long-lasting and distinct mucosal elevation for EMR, but expense and inconvenience have limited its adoption.To evaluate the safety and efficacy of an over-the-counter 0.15% HA preparation for EMR.Retrospective study.Veterans Administration Hospital and university hospital.30 patients with a total of 32 colonic lesions and 1 duodenal lesion.EMR by using HA.En bloc resection rate and complications.EMR was successful in all cases. En bloc resection was achieved in 26 of the 28 lesions up to 25 mm in diameter. Two lesions, both with fibrosis from prior attempted resection, had trace residual tissue necessitating cauterization with argon plasma. Five lesions measuring 30 mm to 60 mm all required piecemeal resection. There was one complication, a postpolypectomy bleed.Small number of patients and retrospective design.EMR may be performed safely and effectively by using an inexpensive, over-the-counter 0.15% HA preparation. Further studies are needed to verify the results of this study and to compare the safety and efficacy of this HA preparation with saline solution.

    View details for DOI 10.1016/j.gie.2012.01.010

    View details for Web of Science ID 000303277400016

    View details for PubMedID 22381528

  • Comparison of EUS-Guided Pancreas Biopsy Techniques Using the Procore (TM) Needle Kothari, S., Chen, A. M., Pai, R., Friedland, S., Park, W. G., Banerjee, S. MOSBY-ELSEVIER. 2012: 145-145
  • Is EGD Necessary in Patients With Positive Fecal Occult Blood Test and Negative Colonoscopy? Kothari, S., Liao, C., Friedland, S., Chen, A. M., Park, W., Banerjee, S. MOSBY-ELSEVIER. 2012: 139-140
  • Post-Procedural Reading of ERCP Spot Films by Radiologists: Has it Improved in the Era of Electronic Medical Records? Kothari, S. T., Friedland, S., Chen, A. M., Banerjee, S. MOSBY-ELSEVIER. 2012: 137-138
  • A New Colonoscope With a Short Turn Radius Allowing Full Withdrawal in Complete Retroflexion Improves Detection of Simulated Polyps Hidden Behind Folds and Flexures in Anatomic Colon Models Mcgill, S. K., Kothari, S., Friedland, S., Chen, A. M., Park, W. G., Pasricha, P. J., Banerjee, S. MOSBY-ELSEVIER. 2012: 215-215
  • Radiation Exposure to Patients During ERCP Is Significantly Higher With Low Volume Endoscopists Kothari, S., Liao, C., Friedland, S., Chen, A. M., Park, W., Banerjee, S. MOSBY-ELSEVIER. 2012: 140-141
  • Water Exchange May Be Superior to Water Immersion Minimizes Colonoscopy Discomfort and Increases Adenoma Detection Rate (ADR) - Review of Recent Randomized Controlled Trials (RCT) Leung, F. W., Amato, A., Ell, C., Friedland, S., Harker, J. O., Hsieh, Y., Leung, J. W., Mann, S. K., Paggi, S., Pohl, J., Radaelli, F., Ramirez, F. C., Siao-Salera, R. M., Terruzzi, V. MOSBY-ELSEVIER. 2012: 276-276
  • Endoscopic Mucosal Resection Using an Inexpensive Over the Counter Hyaluronate Preparation Kothari, S., Banerjee, S., Chen, A. M., Park, W., Friedland, S. MOSBY-ELSEVIER. 2012: 344-345
  • A tandem colonoscopy study of adenoma miss rates during endoscopic training: a venture into uncharted territory GASTROINTESTINAL ENDOSCOPY Munroe, C. A., Lee, P., Copland, A., Wu, K. K., Kaltenbach, T., Soetikno, R. M., Friedland, S. 2012; 75 (3): 561-567


    Tandem colonoscopy is regarded as the reference standard for the evaluation of the adenoma detection rate (ADR) and adenoma miss rate (AMR) during colonoscopy. Pooled results from previous tandem studies yield AMRs of 22%. The AMR of trainees is important to estimate the number of colonoscopies required to develop competence in screening for colorectal neoplasms.To measure the ADR and AMR of trainees as a function of experience.Prospective tandem colonoscopy study at an academic VA medical center. A trainee initially attempted colonoscopy. If the trainee was able to intubate the cecum, the trainee performed the withdrawal, and the colonoscopy was then repeated by the attending physician to assess the AMR.Twelve trainee endoscopists were included in the study. Trainees had between 0 and 33 months of previous endoscopic experience and had done between 0 and 605 previous colonoscopies. A total of 230 patients were evaluated for the study, and 218 patients were enrolled. Complete tandem colonoscopy was performed in 147 patients. There was a 54% ADR. The mean (standard deviation) size of the adenomas in the cohort was 5.9 (5.3) mm. Significant variables in multivariate logistic regression analysis for missed adenomas were trainee experience (P = .011) and patient age (P < .001). The AMR decreased with increasing experience, and it is estimated that 450 colonoscopies are required to attain AMRs of less than 25% in a 60-year-old patient.Single-center study; the attending physician performing the second pass was not blinded to the first pass. The AMR was only analyzed for cases in which the trainee was able to reach the cecum with no or minimal assistance.Our tandem colonoscopy study demonstrates that the AMR decreases as the experience of trainees increases and is a late competency attained during training. Future training may need to incorporate these findings to serve as a basis for determining appropriate training guidelines.

    View details for DOI 10.1016/j.gie.2011.11.037

    View details for Web of Science ID 000301319900017

    View details for PubMedID 22341103

  • Proficiency in the Diagnosis of Nonpolypoid Colorectal Neoplasm Yields High Adenoma Detection Rates DIGESTIVE DISEASES AND SCIENCES Kaltenbach, T., Mcgill, S. K., Kalidindi, V., Friedland, S., Soetikno, R. 2012; 57 (3): 764-770


    Current efforts to prevent colorectal cancer focus on the detection and removal of neoplasms. Nonpolypoid colorectal neoplasms (NP-CRN) have a subtle appearance that can be difficult to recognize during colonoscopy. Endoscopists must first be familiar with the patterns of NP-CRN in order to detect and diagnose them. We studied the adenoma detection rates of endoscopists who had trained to detect NP-CRN, versus endoscopists who had not.Design: Retrospective Nested Case Control Study. Setting: Outpatient Screening Colonoscopy. Participants: Adult Veterans. Intervention: Proficiency in the features and diagnosis of NP-CRN. Main Outcomes Measurements: Adenoma detection.In total, 462 patients had screening colonoscopies-267 by colonoscopists who had trained in the features and diagnosis of NP-CRN. Patient characteristics were similar between groups-the majority were men with a mean age of 62 ± 6 years. Neoplasia was more prevalent (45.7 vs. 34.9%; p = 0.02) in patients evaluated by the trained compared to the conventionally trained group. Trained colonoscopists had a higher adenoma detection rate (0.76 vs. 0.54 adenomas per patient, p < 0.001); removed a higher proportion of neoplasia (77 vs. 35%, p < 0.001); and more frequently diagnosed NP-CRN lesions (OR 2.98, 95% CI: 1.46-6.08) compared to colonoscopists without supplemental training.Endoscopists who are proficient in the detection of NP-CRN had significantly higher adenoma detection rates-of both polypoid and flat adenomas-compared to endoscopists without training, and were more specific in resection of adenomatous over hyperplastic lesions.

    View details for DOI 10.1007/s10620-011-1921-6

    View details for Web of Science ID 000300578200024

    View details for PubMedID 21964768

  • Diagnostic accuracy of cyst fluid amphiregulin in pancreatic cysts BMC GASTROENTEROLOGY Tun, M. T., Pai, R. K., Kwok, S., Dong, A., Gupta, A., Visser, B. C., Norton, J. A., Poultsides, G. A., Banerjee, S., Van Dam, J., Chen, A. M., Friedland, S., Scott, B. A., Verma, R., Lowe, A. W., Park, W. G. 2012; 12


    Accurate tests to diagnose adenocarcinoma and high-grade dysplasia among mucinous pancreatic cysts are clinically needed. This study evaluated the diagnostic utility of amphiregulin (AREG) as a pancreatic cyst fluid biomarker to differentiate non-mucinous, benign mucinous, and malignant mucinous cysts.A single-center retrospective study to evaluate AREG levels in pancreatic cyst fluid by ELISA from 33 patients with a histological gold standard was performed.Among the cyst fluid samples, the median (IQR) AREG levels for non-mucinous (n = 6), benign mucinous (n = 15), and cancerous cysts (n = 15) were 85 pg/ml (47-168), 63 pg/ml (30-847), and 986 pg/ml (417-3160), respectively. A significant difference between benign mucinous and malignant mucinous cysts was observed (p = 0.025). AREG levels greater than 300 pg/ml possessed a diagnostic accuracy for cancer or high-grade dysplasia of 78% (sensitivity 83%, specificity 73%).Cyst fluid AREG levels are significantly higher in cancerous and high-grade dysplastic cysts compared to benign mucinous cysts. Thus AREG exhibits potential clinical utility in the evaluation of pancreatic cysts.

    View details for DOI 10.1186/1471-230X-12-15

    View details for Web of Science ID 000301923400002

    View details for PubMedID 22333441

  • In vivo near-infrared dual-axis confocal microendoscopy in the human lower gastrointestinal tract JOURNAL OF BIOMEDICAL OPTICS Piyawattanametha, W., Ra, H., Qiu, Z., Friedland, S., Liu, J. T., Loewke, K., Kino, G. S., Solgaard, O., Wang, T. D., Mandella, M. J., Contag, C. H. 2012; 17 (2)


    Near-infrared confocal microendoscopy is a promising technique for deep in vivo imaging of tissues and can generate high-resolution cross-sectional images at the micron-scale. We demonstrate the use of a dual-axis confocal (DAC) near-infrared fluorescence microendoscope with a 5.5-mm outer diameter for obtaining clinical images of human colorectal mucosa. High-speed two-dimensional en face scanning was achieved through a microelectromechanical systems (MEMS) scanner while a micromotor was used for adjusting the axial focus. In vivo images of human patients are collected at 5 frames/sec with a field of view of 362×212 ?m(2) and a maximum imaging depth of 140 ?m. During routine endoscopy, indocyanine green (ICG) was topically applied a nonspecific optical contrasting agent to regions of the human colon. The DAC microendoscope was then used to obtain microanatomic images of the mucosa by detecting near-infrared fluorescence from ICG. These results suggest that DAC microendoscopy may have utility for visualizing the anatomical and, perhaps, functional changes associated with colorectal pathology for the early detection of colorectal cancer.

    View details for DOI 10.1117/1.JBO.17.2.021102

    View details for Web of Science ID 000303033600004

    View details for PubMedID 22463020

  • Colonoscopy With Clipping Is Useful in the Diagnosis and Treatment of Diverticular Bleeding CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Kaltenbach, T., Watson, R., Shah, J., Friedland, S., Sato, T., Shergill, A., McQuaid, K., Soetikno, R. 2012; 10 (2): 131-137


    Diverticular bleeding is the most common cause of acute severe lower gastrointestinal bleeding (LGIB) in Western countries. Diagnostic and therapeutic approaches, including endoscopy, radiology, or surgery, have not been standardized. We investigated colonoscopy as a first-line modality to diagnose and manage patients with LGIB.We performed a retrospective study of data collected from 2 tertiary Veterans hospitals of 64 patients (61 men, 76 ± 11 years) with acute severe diverticular bleeding, based on colonoscopy examination. We assessed primary hemostasis using endoscopic clipping for diverticular bleeding and described the bleeding stigmata. We measured early (<30 days) and late rebleeding, blood transfusion requirements, hospital stay and complications.Patients received 3.1 ± 3.0 and 0.9 ± 2.2 U of blood before and after colonoscopy, respectively. Twenty-four of the 64 patients (38%) had diverticular stigmata of recent hemorrhage; and 21 of these patients (88%) were treated successfully using endoscopic clips, without complication or early rebleeding. Hospital stays averaged 6.4 ± 5.6 days. Endoscopic clipping provided primary hemostasis in 9/12 patients (75%) with active diverticular bleeding. During 35 ± 18 months of follow-up, late recurrent diverticular bleeding occurred in 22% of the patients (14/64) after a mean time period of 22 months; 5 of the patients (21%) with stigmata of recent hemorrhage who received clip treatment had rebleeding at 43 months. Rebleeding was self-limited in 8 patients (57%), was clipped in 4 (29%), or was embolized in 2 (14%).Colonoscopy can be a safe first-line diagnostic and therapeutic approach for patients with severe LGIB. Endoscopic clipping provides hemostasis of active diverticular bleeding. Recurrent bleeding occurs in about 21% of patients who were treated with clips, at approximately 4 years; most bleeding is self-limited or can be retreated by endoscopic clipping.

    View details for DOI 10.1016/j.cgh.2011.10.029

    View details for Web of Science ID 000299789800015

    View details for PubMedID 22056302

  • Is colonoscopy best learned underwater? Journal of interventional gastroenterology Friedland, S., Perumpail, R. 2012; 2 (3): 140-141

    View details for PubMedID 23805396

  • Removal of Infused Water Predominantly During Insertion (Water Exchange) is Consistently Associated with a Higher Adenoma Detection Rate - Review of Data in Randomized Controlled Trials of Water Method Colonoscopy Leung, F., Leung, J., Siao-Salera, R., Mann, S., Ramirez, F., Friedland, S., Amato, A., Radaelli, F., Paggi, S., Terruzzi, V. NATURE PUBLISHING GROUP. 2011: S566-S566
  • Removal of infused water predominantly during insertion (water exchange) is consistently associated with a greater reduction of pain score - review of data in RCTs of water method colonoscopy Leung, F., Leung, J., Siao-Salera, R., Mann, S., Ramirez, F., Friedland, S., Amato, A., Radaelli, F., Hsieh, Y. WILEY-BLACKWELL. 2011: 128-129
  • Goff Trans-pancreatic Septotomy Is an Effective and Safe Biliary Cannulation Technique for Patients Who Fail Standard Biliary Cannulation Liao, C., Park, W., Chen, A., Friedland, S., Banerjee, S. NATURE PUBLISHING GROUP. 2011: S56-S56
  • Safety and efficacy of colonoscopy to treat diverticular bleeding - long-term outcomes of a large multicenter cohort Kaltenbach, T., Watson, R., Shah, J., Friedland, S., Sato, T., Shergill, A., McQuaid, K., Soetikno, R. WILEY-BLACKWELL. 2011: 79-79
  • The water method significantly enhances patient-centered outcomes in sedated and unsedated colonoscopy ENDOSCOPY Leung, F. W., Leung, J. W., Mann, S. K., Friedland, S., Ramirez, F. C. 2011; 43 (9): 816-821


    Failure of cecal intubation when using air insufflation during scheduled unsedated colonoscopy in veterans prompted a literature search for a less uncomfortable approach. Water-related maneuvers as "adjuncts" to air insufflation were identified as effective in minimizing discomfort, although medication requirement was not reduced and willingness to repeat unsedated colonoscopy was not addressed. These adjunct maneuvers were combined with turning the air pump off to avoid colon elongation during insertion. Warm water infusion in lieu of air insufflation was evaluated in observational studies. Subsequent refinements evolved into the water method - a combination of air exclusion by aspiration of residual air to minimize angulations at flexures and a dynamic process of water exchange to remove feces in order to clear the view and aid insertion. In subsequent randomized controlled trials, the water method significantly reduced medication requirement, increased the proportion of patients in whom complete unsedated colonoscopy could be achieved, reduced patient recovery time burdens (sedation on demand), decreased abdominal discomfort during and after colonoscopy, enhanced cecal intubation, and increased willingness to repeat the procedure (scheduled unsedated). Supervised education of trainees and self-learning by an experienced colonoscopist were feasible. Lessons learned in developing the water method for optimizing patient-centered outcomes are presented. These proof-of-principle observations merit further research assessment in diverse settings.

    View details for DOI 10.1055/s-0030-1256407

    View details for Web of Science ID 000294543600011

    View details for PubMedID 21611947

  • A novel device for ablation of abnormal esophageal mucosa GASTROINTESTINAL ENDOSCOPY Friedland, S., Triadafilopoulos, G. 2011; 74 (1): 182-188


    Current ablation devices for Barrett's esophagus are effective but have significant limitations.To evaluate a new ablation device.Laboratory and animal model evaluation of the CryoBalloon, a compliant balloon that is simultaneously inflated and cooled by liquid nitrous oxide delivered by using a small, disposable, handheld unit.Cryoablation of esophageal mucosa was performed in 11 swine. Multiple ablations were created in each animal at various ablation times.Animals were euthanized at 4 days (n = 6) or 28 days (n = 5), and histological assessments were performed. At 4 days, the percentage of esophageal mucosa successfully ablated was measured. At 28 days, the circumference of the esophagus at the center of the ablation zone was measured to assess for stricture formation.The CryoBalloon was simple to operate, and balloon contact with tissue was easily maintained. As the ablation time was increased from 6 to 12 seconds, the percentage of mucosa ablated increased from below 60% to above 90%. Maximal effect on the mucosa was reached at 12 seconds. Ablation of up to 14 seconds resulted in minimal luminal narrowing. As the ablation duration increased from 14 to 22 seconds, there was progressive stricture formation evident at 28 days. All of the animals tolerated the treatments without difficulty and, regardless of ablation duration, were able to continue oral intake and gain weight after the procedure.Ablation of normal porcine squamous mucosa may differ from that of human Barrett's esophagus.The CryoBalloon device enables circumferential mucosal ablation in a 1-step process by using a novel, through-the-scope balloon. The maximal effect on the mucosa is achieved with a 12-second application time. Because of its ease of use, this new device merits further study so that we can find its possible role in the treatment of Barrett's esophagus.

    View details for DOI 10.1016/j.gie.2011.03.1119

    View details for Web of Science ID 000292429400027

    View details for PubMedID 21531411

  • Use of the Colonoscope Training Model with the Colonoscope 3D Imaging Probe Improved Trainee Colonoscopy Performance: A Pilot Study DIGESTIVE DISEASES AND SCIENCES Kaltenbach, T., Leung, C., Wu, K., Yan, K., Friedland, S., Soetikno, R. 2011; 56 (5): 1496-1502


    Colonoscopy insertion is difficult to teach due to the inability of current training models to provide realistic tactile sensation with simultaneous three-dimensional (3D) colonoscope display.To assess the influence of a simulator consisting of a colon model coupled with 3D instrument visualization on trainee colonoscopy performance.Pilot study using the simulator model with three trainees who were not proficient in colonoscopy. At random times over a 6-week period, trainees participated in an individualized half-day session using the Colonoscope Training Model and a colonoscope equipped with a 3D magnetic probe imaging system (ScopeGuide) in six standardized cases. A blinded supervising instructor graded patient-based colonoscopy performance over the 6-week period, and we independently analyzed the 2-week period before and after the intervention. We also measured cecal intubation and withdrawal times and medication requirements.Trainees performed 86 patient-based colonoscopies. Following the intervention, the colonoscopy performance score improved from 4.4 ± 2.3 to 5.9 ± 2.4 (p = 0.005). Trainees had a 76% cecal intubation rate following the session as compared to 43% before training (p = 0.004), while utilizing less time, 14 ± 7 versus 18 ± 11 min (p = 0.056) and less medication (p > 0.05).Colonoscopy simulation using the Colonoscope Training Model and the ScopeGuide produced an immediate and large effect on trainee colonoscopy performance.

    View details for DOI 10.1007/s10620-011-1614-1

    View details for Web of Science ID 000289899200033

    View details for PubMedID 21409379

  • Learning and teaching the water method (with videos). Journal of interventional gastroenterology Friedland, S., Leung, F. W. 2011; 1 (3): 127-129


    The water method is an insertion technique for colonoscopy which has recently become popular owing to its demonstrated ability to decrease patient pain and sedation requirements. This review focuses on learning and teaching the water method. Data from the United States and Asia suggests that trainees at all levels of experience can safely learn and utilize the water method. Demonstrated benefits in some of the reviewed studies include lessened sedation requirements, less pain for patients and increased cecal intubation rates in minimally sedated patients. These benefits are realized without compromising safety, adenoma detection rates, or procedure times.

    View details for PubMedID 22163083

  • The water immersion technique for colonoscopy insertion. Gastroenterology & hepatology Friedland, S. 2010; 6 (9): 555-556

    View details for PubMedID 21088743

  • Integrating urgent multidetector CT scanning in the diagnostic algorithm of active lower GI bleeding GASTROINTESTINAL ENDOSCOPY Copland, A., Munroe, C. A., Friedland, S., Triadafilopoulos, G. 2010; 72 (2): 402-405

    View details for DOI 10.1016/j.gie.2010.04.014

    View details for Web of Science ID 000280778800027

    View details for PubMedID 20674629

  • Water immersion versus standard colonoscopy insertion technique: randomized trial shows promise for minimal sedation ENDOSCOPY Leung, C. W., Kaltenbach, T., Soetikno, R., Wu, K. K., Leung, F. W., Friedland, S. 2010; 42 (7): 557-563


    Water immersion is an alternative colonoscopy technique that may reduce discomfort and facilitate insertion of the instrument. This was a prospective study to compare the success of colonoscopy with minimal sedation using water immersion and conventional air insufflation.A total of 229 patients were randomized to either water immersion or the standard air insertion technique. The primary outcome was success of minimal sedation colonoscopy, which was defined as reaching the cecum without additional sedation, exchange of the adult colonoscope or hands-on assistance for trainees. Patient comfort and satisfaction were also assessed.Successful minimal-sedation colonoscopy was achieved in 51 % of the water immersion group compared with 28 % in the standard air group (OR, 2.66; 95 % CI 1.48 - 4.79; P = 0.0004). Attending physicians had 79 % success with water immersion compared with 47 % with air insufflation (OR, 4.19; 95 % CI 1.5 - 12.17; P = 0.002), whereas trainees had 34 % success with water compared with 16 % using air (OR, 2.75; 95 % CI 1.15 - 6.86; P = 0.01). Using the water method, endoscopists intubated the cecum faster and this was particularly notable for trainees (13.0 +/- 7.5 minutes with water vs. 20.5 +/- 13.9 minutes with air; P = 0.0001). Total procedure time was significantly shorter with water for both experienced and trainee endoscopists ( P < 0.05). Patients reported less intraprocedural pain with water compared with air (4.1 +/- 2.7 vs. 5.3 +/- 2.7; P = 0.001), with a similar level of satisfaction. There was no difference in the neoplasm detection rates between the groups.Colonoscopy insertion using water immersion increases the success rate of minimal sedation colonoscopy. Use of the technique leads to a decrease in discomfort, time to reach the cecum, and the amount of sedative and analgesic used, without compromising patient satisfaction.

    View details for DOI 10.1055/s-0029-1244231

    View details for Web of Science ID 000279406900006

    View details for PubMedID 20593332

  • Long-Term Impact of Capsule Endoscopy in Patients Referred for Iron-Deficiency Anemia DIGESTIVE DISEASES AND SCIENCES Sheibani, S., Levesque, B. G., Friedland, S., Roost, J., Gerson, L. B. 2010; 55 (3): 703-708


    Video capsule endoscopy (VCE) is recommended as the third diagnostic test for patients with iron-deficiency anemia (IDA) after a normal upper endoscopy and colonoscopy.To study long-term outcomes after VCE in patients with IDA.We performed a retrospective study of VCE studies performed at Stanford University Hospital or the VA Palo Alto Health Care System from 2002 to 2006. We assessed endoscopic or radiographic procedures performed post-CE and contacted patients by telephone in order to determine current medical status and potential resolution of anemia since the VCE.We invited 153 patients to participate, and 82 (54%) patients agreed to enroll including 57 patients with IDA and 25 patients with overt gastrointestinal bleeding. The overt group received more transfusions pre-CE (P < 0.05). The mean follow-up time was 36 +/- 16 months (median 33 months, range 14-67) in the IDA referral group and 40 +/- 16 months (median 39 months, range 17-69) in the overt bleeding group (P = 0.3). Positive findings on VCE were detected in 35 (60%) and 15 (60%) patients in the IDA referral and overt groups, respectively (P= 1.0). Of the 35 patients in the IDA referral group with significant VCE findings, 15 underwent therapeutic procedures, while 20 were managed conservatively. Over the mean follow-up period, 23% of the IDA referral group and 22% of the overt group remained anemic (P = 0.30).Most patients referred for VCE examination to evaluate IDA were no longer anemic at 36 months of follow-up, with or without therapeutic intervention.

    View details for DOI 10.1007/s10620-009-1046-3

    View details for Web of Science ID 000274617500019

    View details for PubMedID 19941072

  • Meckel's Diverticulum with Gastrointestinal Bleeding: Role of Computed Tomography in Diagnosis DIGESTIVE DISEASES AND SCIENCES Munroe, C. A., Copland, A., Pai, R., Friedland, S., Triadafilopoulos, G. 2010; 55 (2): 242-244

    View details for DOI 10.1007/s10620-009-1029-4

    View details for Web of Science ID 000273520900005

    View details for PubMedID 19888654

  • From Bench to Bedside with Advanced Confocal Microendoscope 2010 IEEE PHOTONICS SOCIETY WINTER TOPICALS MEETING SERIES Piyawattanametha, W., Mandella, M. J., Ra, H., Liu, J. T., Friedland, S., Qiu, Z., Kino, G. S., Wang, T. D., Contag, C. H., Solgaard, O. 2010: 83-84
  • Use of an endoscope-compatible probe to detect colonic dysplasia with Fourier transform infrared spectroscopy JOURNAL OF BIOMEDICAL OPTICS Mackanos, M. A., Hargrove, J., Wolters, R., Du, C. B., Friedland, S., Soetikno, R. M., Contag, C. H., Arroyo, M. R., Crawford, J. M., Wang, T. D. 2009; 14 (4)


    Fourier transform infrared (FTIR) spectroscopy is sensitive to the molecular composition of tissue and has the potential to identify premalignant tissue (dysplasia) as an adjunct to endoscopy. We demonstrate collection of mid-infrared absorption spectra with a silver halide (AgCl(0.4)Br(0.6)) optical fiber and use spectral preprocessing to identify optimal subranges that classify colonic mucosa as normal, hyperplasia, or dysplasia. We collected spectra (n=83) in the 950 to 1800 cm(-1) regime on biopsy specimens obtained from human subjects (n=37). Subtle differences in the magnitude of the absorbance peaks at specific wave numbers were observed. The best double binary algorithm for distinguishing normal-versus-dysplasia and hyperplasia-versus-dysplasia was determined from an exhaustive search of spectral intervals and preprocessing techniques. Partial least squares discriminant analysis was used to classify the spectra using a leave-one-subject-out cross-validation strategy. The results were compared with histology reviewed independently by two gastrointestinal pathologists. The optimal thresholds identified resulted in an overall sensitivity, specificity, accuracy, and positive predictive value of 96%, 92%, 93%, and 82%, respectively. These results indicated that mid-infrared absorption spectra collected remotely with an optical fiber can be used to identify colonic dysplasia with high accuracy, suggesting that continued development of this technique for the early detection of cancer is promising.

    View details for DOI 10.1117/1.3174387

    View details for Web of Science ID 000270540100013

    View details for PubMedID 19725718

  • Endoscopic necrosectomy of organized pancreatic necrosis: a currently practiced NOTES procedure JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY Friedland, S., Kaltenbach, T., Sugimoto, M., Soetikno, R. 2009; 16 (3): 266-269


    Endoscopic necrosectomy is now an established minimally invasive method for treatment of organized pancreatic necrosis.Review of methods and results of endoscopic treatment of pancreatic necrosis.Reports by multiple groups have demonstrated favorable results of endoscopic necrosectomy. The mortality of critically ill patients undergoing endoscopic treatment in several series is approximately 10%. Some patients will eventually also require surgery for situations such as complete pancreatic duct disruption, but even in these cases endoscopic necrosectomy is useful because pancreatic surgery can often be delayed until the patient is stable.Endoscopic necrosectomy will likely assume an increasing role in the treatment of pancreatic necrosis. This should result in reduced morbidity and mortality in these critically ill patients.

    View details for DOI 10.1007/s00534-009-0088-4

    View details for Web of Science ID 000265566800005

    View details for PubMedID 19350193

  • Colonoscopic polypectomy in anticoagulated patients WORLD JOURNAL OF GASTROENTEROLOGY Friedland, S., Sedehi, D., Soetikno, R. 2009; 15 (16): 1973-1976


    To review our experience performing polypectomy in anticoagulated patients without interruption of anticoagulation.Retrospective chart review at the Veterans Affairs Palo Alto Health Care System. Two hundred and twenty five polypectomies were performed in 123 patients. Patients followed a standardized protocol that included stopping warfarin for 36 h to avoid supratherapeutic anticoagulation from the bowel preparation. Patients with lesions larger than 1 cm were generally rescheduled for polypectomy off warfarin. Endoscopic clips were routinely applied prophylactically.One patient (0.8%, 95% CI: 0.1%-4.5%) developed major post-polypectomy bleeding that required transfusion. Two others (1.6%, 95% CI: 0.5%-5.7%) had self-limited hematochezia at home and did not seek medical attention. The average polyp size was 5.1 +/- 2.2 mm.Polypectomy can be performed in therapeutically anticoagulated patients with lesions up to 1 cm in size with an acceptable bleeding rate.

    View details for DOI 10.3748/wjg.15.1973

    View details for Web of Science ID 000265619800008

    View details for PubMedID 19399929

  • Safe endoscopic treatment of large colonic lipomas using endoscopic looping technique DIGESTIVE AND LIVER DISEASE Kaltenbach, T., Milkes, D., Friedland, S., Soetikno, R. 2008; 40 (12): 958-961


    Colonic lipomas are benign, submucosal tumours that are usually asymptomatic. Typically, they are incidentally diagnosed during colonoscopy. Due to a low prevalence, the natural history of lipomas remains largely unknown. While large (>2 cm) lesions can cause symptoms and complications, their endoscopic treatment is not routinely recommended because of prior reports of a high rate of perforation.We used a standardized technique of polypectomy, using endoscopic looping to resect large colonic lipomas in 8 patients and followed their clinical outcomes.The mean lipoma size was 3.8+/-1.2 cm (range 2.5-6 cm). No patient developed bleeding or perforation. On follow-up (mean=13.5 months, range 2-29), there was one small residual lesion.Colonic lipomas larger than 2 cm can be safely and efficaciously removed using endoloop assisted polypectomy technique.

    View details for DOI 10.1016/j.dld.2008.03.010

    View details for Web of Science ID 000261804600008

    View details for PubMedID 18434264

  • A randomised tandem colonoscopy trial of narrow band imaging versus white light examination to compare neoplasia miss rates GUT Kaltenbach, T., Friedland, S., Soetikno, R. 2008; 57 (10): 1406-1412


    Colonoscopy, the "gold standard" screening test for colorectal cancer (CRC), has known diagnostic limitations. Advances in endoscope technology have focused on improving mucosal visualisation. In addition to increased angle of view and resolution features, recent colonoscopes have non-white-light optics, such as narrow band imaging (NBI), to enhance image contrast. We aimed to study the neoplasia diagnostic characteristics of NBI, by comparing the neoplasm miss rate when the colonoscopy was performed under NBI versus white light (WL).Randomised controlled trial.US Veterans hospital.Elective colonoscopy adults.We randomly assigned patients to undergo a colonoscopic examination using NBI or WL. All patients underwent a second examination using WL, as the reference standard.The primary end point was the difference in the neoplasm miss rate, and secondary outcome was the neoplasm detection rate.In 276 tandem colonoscopy patients, there was no significant difference of miss or detection rates between NBI or WL colonoscopy techniques. Of the 135 patients in the NBI group, 17 patients (12.6%; 95% confidence interval (CI) 7.5 to 19.4%) had a missed neoplasm, as compared with 17 of the 141 patients (12.1%; 95% CI 7.2 to 18.6%) in the WL group, with a miss rate risk difference of 0.5% (95% CI -7.2 to 8.3). 130 patients (47%) had at least one neoplasm. Missed lesions with NBI showed similar characteristics to those missed with WL. All missed neoplasms were tubular adenomas, the majority (78%) was < or = 5 mm and none were larger than 1 cm (one-sided 95% CI up to 1%). Nonpolypoid lesions represented 35% (13/37) of missed neoplasms.NBI did not improve the colorectal neoplasm miss rate compared to WL; the miss rate for advanced adenomas was less than 1% and for all adenomas was 12%. The neoplasm detection rates were similar high using NBI or WL; almost a half the study patients had at least one adenoma. identifier: NCT00628147.

    View details for DOI 10.1136/gut.2007.137984

    View details for Web of Science ID 000259198800017

    View details for PubMedID 18523025

  • Integrated gastrointestinal imaging and therapy GASTROENTEROLOGY Soetikno, R., Kaltenbach, T., Binmoeller, K., Friedland, S., Burdon, T. 2008; 134 (5): 1290-1292

    View details for DOI 10.1053/j.gastro.2008.03.047

    View details for Web of Science ID 000255676700008

    View details for PubMedID 18471503

  • Detection of colonic dysplasia in vivo using a targeted heptapeptide and confocal microendoscopy NATURE MEDICINE Hsiung, P., Hardy, J., Friedland, S., Soetikno, R., Du, C. B., Wu, A. P., Sahbaie, P., Crawford, J. M., Lowe, A. W., Contag, C. H., Wang, T. D. 2008; 14 (4): 454-458


    A combination of targeted probes and new imaging technologies provides a powerful set of tools with the potential to improve the early detection of cancer. To develop a probe for detecting colon cancer, we screened phage display peptide libraries against fresh human colonic adenomas for high-affinity ligands with preferential binding to premalignant tissue. We identified a specific heptapeptide sequence, VRPMPLQ, which we synthesized, conjugated with fluorescein and tested in patients undergoing colonoscopy. We imaged topically administered peptide using a fluorescence confocal microendoscope delivered through the instrument channel of a standard colonoscope. In vivo images were acquired at 12 frames per second with 50-microm working distance and 2.5-microm (transverse) and 20-microm (axial) resolution. The fluorescein-conjugated peptide bound more strongly to dysplastic colonocytes than to adjacent normal cells with 81% sensitivity and 82% specificity. This methodology represents a promising diagnostic imaging approach for the early detection of colorectal cancer and potentially of other epithelial malignancies.

    View details for DOI 10.1038/nm1692

    View details for Web of Science ID 000254674100034

    View details for PubMedID 18345013

  • Prevalence of nonpolypoid (flat and depressed) colorectal neoplasms in asymptomatic and symptomatic adults JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Soetikno, R. M., Kaltenbach, T., Rouse, R. V., Park, W., Maheshwari, A., Sato, T., Matsui, S., Friedland, S. 2008; 299 (9): 1027-1035


    Colorectal cancer is the second leading cause of cancer death in the United States. Prevention has focused on the detection and removal of polypoid neoplasms. Data are limited on the significance of nonpolypoid colorectal neoplasms (NP-CRNs).To determine the prevalence of NP-CRNs in a veterans hospital population and to characterize their association with colorectal cancer.Cross-sectional study at a veterans hospital in California with 1819 patients undergoing elective colonoscopy from July 2003 to June 2004.Endoscopic appearance, location, size, histology, and depth of invasion of neoplasms.The overall prevalence of NP-CRNs was 9.35% (95% confidence interval [95% CI], 8.05%-10.78%; n = 170). The prevalence of NP-CRNs in the subpopulations for screening, surveillance, and symptoms was 5.84% (95% CI, 4.13%-8.00%; n = 36), 15.44% (95% CI, 12.76%-18.44%; n = 101), and 6.01% (95% CI, 4.17%-8.34%; n = 33), respectively. The overall prevalence of NP-CRNs with in situ or submucosal invasive carcinoma was 0.82% (95% CI, 0.46%-1.36%; n = 15); in the screening population, the prevalence was 0.32% (95% CI, 0.04%-1.17%; n = 2). Overall, NP-CRNs were more likely to contain carcinoma (odds ratio, 9.78; 95% CI, 3.93-24.4) than polypoid lesions, irrespective of the size. The positive size-adjusted association of NP-CRNs with in situ or submucosal invasive carcinoma was also observed in subpopulations for screening (odds ratio, 2.01; 95% CI, 0.27-15.3) and surveillance (odds ratio, 63.7; 95% CI, 9.41-431). The depressed type had the highest risk (33%). Nonpolypoid colorectal neoplasms containing carcinoma were smaller in diameter as compared with the polypoid ones (mean [SD] diameter, 15.9 [10.2] mm vs 19.2 [9.6] mm, respectively). The procedure times did not change appreciably as compared with historical controls.In this group of veteran patients, NP-CRNs were relatively common lesions diagnosed during routine colonoscopy and had a greater association with carcinoma compared with polypoid neoplasms, irrespective of size.

    View details for Web of Science ID 000253644800020

    View details for PubMedID 18319413

  • American gastroenterological association (AGA) institute technology assessment on image-enhanced endoscopy GASTROENTEROLOGY Kaltenbach, T., Sano, Y., Friedland, S., Soetikno, R. 2008; 134 (1): 327-340


    This document presents the official recommendations of the American Gastroenterological Association (AGA) Institute Technology Assessment on "Image-Enhanced Endoscopy." It was approved by the Clinical Practice and Economics Committee on August 3, 2007, and by the AGA Institute Governing Board September 27, 2007.

    View details for DOI 10.1053/j.gastro.2007.10.062

    View details for Web of Science ID 000252066400037

    View details for PubMedID 18061178

  • Small caliber overtube-assisted colonoscopy WORLD JOURNAL OF GASTROENTEROLOGY Friedland, S., Soetikno, R. M. 2007; 13 (44): 5933-5937


    To combine the benefits of a new thin flexible scope with elimination of excessive looping through the use of an overtube.Three separate retrospective series. Series 1: 25 consecutive male patients undergoing unsedated colonoscopy using the new device at a Veteran's hospital in the United States. Series 2: 75 male patients undergoing routine colonoscopy using an adult colonoscope, pediatric colonoscope, or the new device. Series 3: 35 patients who had incomplete colonoscopies using standard instruments.Complete colonoscopy was achieved in all 25 patients in the unsedated series with a median cecal intubation time of 6 min and a median maximal pain score of 3 on a 0-10 scale. In the 75 routine cases, there was significantly less pain with the thin scope compared to standard adult and pediatric colonoscopes. Of the 35 patients in the previously incomplete colonoscopy series, 33 were completed with the new system.Small caliber overtube-assisted colonoscopy is less painful than colonoscopy with standard adult and pediatric colonoscopes. Male patients could undergo unsedated colonoscopy with the new system with relatively little pain. The new device is also useful for most patients in whom colonoscopy cannot be completed with standard instruments.

    View details for Web of Science ID 000250799800015

    View details for PubMedID 17990359

  • Functional imaging of colonic mucosa with a fibered Confocal microscope for real-time in vivo pathology CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Wang, T. D., Friedland, S., Sahbaie, P., Soetikno, R., Hsiung, P., Liu, J. T., Crawford, J. M., Contag, C. H. 2007; 5 (11): 1300-1305


    Histologic interpretation of disease currently is performed with static images of excised tissues, and is limited by processing artifact, sampling error, and interpretive variability. The aim of this study was to show the use of functional optical imaging of viable mucosa for quantitative evaluation of colonic neoplasia in real time.Fluorescein (5 mg/mL) was administered topically in 54 human subjects undergoing screening colonoscopy. Fluorescence images were collected with 488-nm excitation at 12 frames/s with the confocal microendoscopy system. Movement of fluorescein in the transient period (<5 s) and the lamina propria:crypt contrast ratio in the steady-state phase (>5 s) were quantified.Normal mucosa showed circular crypts with uniform size, hyperplasia revealed proliferative glands with serrated lumens, and adenomas displayed distorted elongated glands. For t less than 5 seconds, fluorescein passed through normal epithelium with a peak speed of 1.14 +/- 0.09 microm/s at t = 0.5 seconds, and accumulated into lamina propria as points of fluorescence that moved through the interglandular space with an average speed of 41.7 +/- 3.4 microm/s. Passage of fluorescein through adenomatous mucosa was delayed substantially. For t greater than 5 seconds, high sensitivity, specificity, and accuracy was achieved using a discriminant function to evaluate the contrast ratio to distinguish normal from lesional mucosa (91%, 87%, and 89%, respectively; P < .001), hyperplasia from adenoma (97%, 96%, and 96%, respectively; P < .001), and tubular from villous adenoma (100%, 92%, and 93%, respectively; P < .001).Confocal imaging can be performed in vivo to assess the functional behavior of tissue in real time for providing pathologic interpretation, representing a new method for histologic evaluation.

    View details for DOI 10.1016/j.cgh.2007.07.013

    View details for Web of Science ID 000250944900012

    View details for PubMedID 17936692

  • Detection of endogenous biomolecules in Barrett's esophagus by Fourier transform infrared spectroscopy PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA Wang, T. D., Triadafilopoulos, G., Crawford, J. M., Dixon, L. R., Bhandari, T., Sahbaie, P., Friediand, S., Soetikno, R., Contag, C. H. 2007; 104 (40): 15864-15869


    Fourier transform infrared (FTIR) spectroscopy provides a unique molecular fingerprint of tissue from endogenous sources of light absorption; however, specific molecular components of the overall FTIR signature of precancer have not been characterized. In attenuated total reflectance mode, infrared light penetrates only a few microns of the tissue surface, and the influence of water on the spectra can be minimized, allowing for the analyses of the molecular composition of tissues. Here, spectra were collected from 98 excised specimens of the distal esophagus, including 38 squamous, 38 intestinal metaplasia (Barrett's), and 22 gastric, obtained endoscopically from 32 patients. We show that DNA, protein, glycogen, and glycoprotein comprise the principal sources of infrared absorption in the 950- to 1,800-cm(-1) regime. The concentrations of these biomolecules can be quantified by using a partial least-squares fit and used to classify disease states with high sensitivity, specificity, and accuracy. Moreover, use of FTIR to detect premalignant (dysplastic) mucosa results in a sensitivity, specificity, positive predictive value, and total accuracy of 92%, 80%, 92%, and 89%, respectively, and leads to a better interobserver agreement between two gastrointestinal pathologists for dysplasia (kappa = 0.72) versus histology alone (kappa = 0.52). Here, we demonstrate that the concentration of specific biomolecules can be determined from the FTIR spectra collected in attenuated total reflectance mode and can be used for predicting the underlying histopathology, which will contribute to the early detection and rapid staging of many diseases.

    View details for DOI 10.1073/pnas.0707567104

    View details for Web of Science ID 000249942700049

    View details for PubMedID 17901200

  • Long-term use of proton pump inhibitors does not affect the frequency, growth, or histologic characteristics of colon adenomas ALIMENTARY PHARMACOLOGY & THERAPEUTICS Singh, M., Dhindsa, G., Friedland, S., Triadafilopoulos, G. 2007; 26 (7): 1051-1061


    The clinical significance of the trophic effects of long-term proton pump inhibitors (PPI)-related hypergastrinemia on colon polyps remains unknown.To study the frequency, growth, and histology of colon polyps in patients on chronic PPI therapy (cases), compared to those not receiving acid suppression (controls).Medical records of 2868 consecutive patients who underwent two or more colonoscopies, performed 3 or more months apart were reviewed. Cases (116) that used PPIs between the two colonoscopies were then compared to controls (194).Demographics and risk factors for colon cancer were comparable between the two groups. At baseline the mean frequency and size of adenomatous polyps were similar in cases and controls (P > 0.05) and at follow-up, these were 0.89 and 1.18 (P > 0.05; 95% CI of -0.08 to 0.66) and 4.09 mm and 4.00 mm (P > 0.05; 95% CI -2.29 to 2.11), respectively with no significant change. However, control group had a higher mean frequency and size of hyperplastic polyps at baseline as well as at follow-up colonoscopy (P < 0.05).The long-term use of PPI does not influence the frequency, growth, or histology of adenomatous polyps, but is associated with a reduction in both baseline and interval development of hyperplastic polyps.

    View details for DOI 10.1111/j.1365-2036.2007.03450.x

    View details for Web of Science ID 000249482000009

    View details for PubMedID 17877512

  • Short- and long-term outcomes of standardized EMR of nonpolypoid (flat and depressed) colorectal lesions >= 1 cm (with video) GASTROINTESTINAL ENDOSCOPY Kaltenbach, T., Friedland, S., Maheshwari, A., Ouyang, D., Rouse, R. V., Wren, S., Soetikno, R. 2007; 65 (6): 857-865


    Nonpolypoid (flat and depressed) colorectal lesions are increasingly recognized. Their endoscopic removal requires specialized EMR techniques, which are more complex to perform. Outcomes data on EMR of nonpolypoid neoplasms in the United States is needed.To determine the safety and efficacy of EMR in the resection of nonpolypoid colorectal neoplasms > or = 1 cm.Retrospective analysis.Veterans Affairs Palo Alto Health Care System.Over a 5-year period, patients who underwent EMR for nonpolypoid colorectal lesions > or = 1 cm.A standardized approach that included lesion assessment, classification, inject-and-cut EMR technique, reassessment, and treatment of residual tissue.Complete resection, bleeding, perforation, development of advanced cancer, and death.A total of 100 patients (125 lesions: 117 flat and 8 depressed) met inclusion criteria. Mean size was 16.7 +/- 7 mm (range, 10-50 mm). Histology included 5 submucosal invasive cancers, 5 carcinomas in situ, and 91 adenomas. Thirty-eight patients (48 lesions) did not receive surveillance colonoscopy: 8 had surgery, 16 had hyperplastic pathology, and 14 did not undergo repeat examination. Surveillance colonoscopy was performed on 62 patients (77 lesions). Complete resection was achieved in 100% of these patients after 1 to 3 surveillance colonoscopies. All patients received follow-up (mean [standard deviation] = 4.5 +/- 1.4 years); none developed colorectal cancer or metastasis.Single endoscopist, retrospective study.A standardized EMR (inject-and-cut) technique is a safe and curative treatment option in nonpolypoid colorectal neoplasms (> or = 1 cm) in the United States.

    View details for DOI 10.1016/j.gie.2006.11.035

    View details for Web of Science ID 000246217300017

    View details for PubMedID 17466205

  • Transnasal small-caliber esophagogastroduodenoscopy for preoperative evaluation of the high-risk morbidly obese patient SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Alami, R. S., Schuster, R., Friedland, S., Curet, M. J., Wren, S. M., Soetikno, R., Morton, J. M., Safadi, B. Y. 2007; 21 (5): 758-760


    Esophagogastroduodenoscopy (EGD) is an important facet of the preoperative evaluation for bariatric surgery. Morbidly obese patients are at high risk for airway complications during this procedure, and an attractive alternative is transnasal EGD. This report describes a series of patients evaluated successfully using this technique.All patients undergoing preoperative transnasal small-caliber EGD for morbid obesity surgery between September 2004 and June 2005 at a Veterans Affairs Hospital were included in the analysis. The variables assessed were the adequacy of the examination, patient tolerance, the need for sedation, and the ability to perform interventions.The study enrolled 25 patients (17 men and 8 women) with an average age of 55 years (range, 44-63 years) and an average body mass index (BMI) of 47 kg/m2 (range, 38-69 kg/m2). All the patients met the 1991 National Institutes of Health (NIH) Consensus Conference Criteria for bariatric surgery and were undergoing preoperative evaluation. The most common comorbidities were hypertension (82%), diabetes mellitus (80%), and obstructive sleep apnea (68%). All 25 patients had successful cannulation of the duodenum's second portion with excellent tolerance. There were no sedation requirements for 23 (92%) of the 25 patients. Significant pathology was found in 14 (56%) of the 25 patients, including hiatal hernia (28%), gastritis (16%), esophageal intestinal metaplasia (16%), esophagitis (12%), gastric polyps (8%), gastric ulcer (4%) and esophageal varices (4%). Biopsies were indicated for 12 patients and successful for all 12 (100%).Transnasal small-caliber EGD is a feasible and safe alternative to conventional EGD for the preoperative evaluation of patients undergoing bariatric surgery. It requires minimal to no sedation in a population at high risk for complications in this setting. In addition, this technique is effective in identifying pathology that requires preoperative treatment and offers a complete examination with biopsy capabilities. This technique should be considered for all morbidly obese patients at high risk for airway compromise during EGD.

    View details for DOI 10.1007/s00464-006-9101-z

    View details for Web of Science ID 000246351800013

    View details for PubMedID 17235723

  • Diagnosis of chronic mesenteric ischemia by visible light spectroscopy during endoscopy GASTROINTESTINAL ENDOSCOPY Friedland, S., Benaron, D., Coogan, S., Sze, D. Y., Soetikno, R. 2007; 65 (2): 294-300


    Chronic mesenteric ischemia can be difficult to diagnose by means of currently available clinical techniques. We developed a novel endoscopic device for objective measurement of GI mucosal ischemia.Our purpose was to evaluate the performance of the device in patients with chronic mesenteric ischemia.A fiberoptic catheter-based visible light spectroscopy oximeter (T-Stat 303 Microvascular Oximeter, Spectros, Portola Valley, Calif) was used to evaluate 30 healthy control subjects and 3 patients with chronic mesenteric ischemia before and after successful percutaneous stenting.Veterans Affairs Palo Alto Health Care System hospital.Normal mucosal (capillary) hemoglobin oxygen saturation was 60% to 73% in the duodenum and jejunum. In the 3 patients with chronic mesenteric ischemia, ischemic areas in the duodenum or proximal jejunum were found with mucosal saturations of 16% to 30%. After successful angioplasty and stent placement of the celiac, superior mesenteric, or inferior mesenteric arteries, the mucosal saturation in these areas increased to 51% to 60%.This preliminary study suggests that chronic mesenteric ischemia is detectable during endoscopy by use of visible light spectroscopy and that successful endovascular treatment results in near normalization of mucosal oxygen saturation.

    View details for DOI 10.1016/j.gie.2006.05.007

    View details for Web of Science ID 000244041900023

    View details for PubMedID 17137857

  • Use of a double balloon enteroscope facilitates caecal intubation after incomplete colonoscopy with a standard colonoscope DIGESTIVE AND LIVER DISEASE Kaltenbach, T., Soetikno, R., Friedland, S. 2006; 38 (12): 921-925


    Caecal intubation is a necessary step in the complete endoscopic evaluation of the colon. Studies have estimated that experienced colonoscopists may fail to reach the caecum in up to 10% of cases.To evaluate the utility of the double balloon enteroscope used for complete examination of the colon in patients with incomplete standard colonoscopy.Twenty consecutive patients with incomplete colonoscopies within the Veterans Affairs Palo Alto Health Care System. Mean age of 66 years (S.D.+/-12 years, range 46-84), 16 men.Prospective single-centre case series on the caecal intubation rate using standard double balloon enteroscope technique in patients with previous incomplete conventional colonoscopy.Use of the standard double balloon enteroscope technique permitted complete colonoscopy to be achieved in 95% of the patients (19/20). Seven patients (35%) had significant pathology beyond the extent of the prior incomplete colonoscopy. We performed endoscopic mucosal resection, polypectomy or biopsy. The mean time to reach the caecum was 28 min (S.D.+/-20 min, range 6-90 min). The sedation was similar to conventional colonoscopy. No complications occurred.The double balloon enteroscope technology and technique can be used to complete examination of the colon in patients who were referred because of incomplete standard colonoscopy.

    View details for DOI 10.1016/j.dld.2006.08.003

    View details for Web of Science ID 000243715600010

    View details for PubMedID 16990055

  • Dual-axes confocal reflectance microscope for distinguishing colonic neoplasia JOURNAL OF BIOMEDICAL OPTICS Liu, J. T., Mandella, M. J., Friedland, S., Soetikno, R., Crawford, J. M., Contag, C. H., Kino, G. S., Wang, T. D. 2006; 11 (5)


    A dual-axes confocal reflectance microscope has been developed that utilizes a narrowband laser at 1310 nm to achieve high axial resolution, image contrast, field of view, and tissue penetration for distinguishing among normal, hyperplastic, and dysplastic colonic mucosa ex vivo. Light is collected off-axis using a low numerical aperture objective to obtain vertical image sections, with 4- to 5-microm resolution, at tissue depths up to 610 microm. Post-objective scanning enables a large field of view (610 x 640 microm), and balanced-heterodyne detection provides sensitivity to collect vertical sections at one frame per second. System optics are optimized to effectively reject out-of-focus scattered light without use of a low-coherence gate. This design is scalable to millimeter dimensions, and the results demonstrate the potential for a miniature instrument to detect precancerous tissues, and hence to perform in vivo histopathology.

    View details for DOI 10.1117/1.2363363

    View details for Web of Science ID 000242576900023

    View details for PubMedID 17092168

  • Long-term proton pump inhibitors (PPIs) use does not affect the frequency, growth, or histologic characteristics of colon polyps Singh, M., Dhindsa, G., Friedland, S., Triadafilopoulos, G. NATURE PUBLISHING GROUP. 2006: S215-S215
  • Colonoscopy with polypectomy in anticoagulated patients GASTROINTESTINAL ENDOSCOPY Friedland, S., Soetikno, R. 2006; 64 (1): 98-100


    According to current practice guidelines for performance of colonoscopy in patients requiring long-term anticoagulation, polypectomy is considered a high-risk procedure for which anticoagulation must temporarily be discontinued. However, these guidelines are based on expert opinion, and the bleeding risk after polypectomy in anticoagulated patients is not known.Measure the risk of postpolypectomy bleeding in patients who undergo colonoscopic polypectomy while anticoagulated.Retrospective review of patients who underwent polypectomy without discontinuation of anticoagulation.Veterans Administration Palo Alto Health Care System.Forty-one polypectomies were performed in 21 patients. All patients had been receiving long-term anticoagulation with warfarin; the average international normalized ratio was 2.3 (range 1.4-4.9; normal 0.9-1.2). To prevent supratherapeutic anticoagulation, warfarin was withheld for 36 hours before the procedure while the patients were on a liquid diet. The average polyp size was 5 mm (range 3-10 mm).All patients underwent polypectomy followed immediately by prophylactic application of one or two clips to prevent bleeding.Rate of postpolypectomy bleeding.There were no episodes of postpolypectomy bleeding. The 95% CI for the risk of bleeding was 0% to 8.6% when analyzed per polypectomy and 0% to 15% when analyzed per patient.Small single-center retrospective study.Our experience suggests that small polyps can be removed with a very low risk of bleeding when clips are applied immediately after polypectomy. If these results can be confirmed in a larger multicenter study, our protocol may become an alternative to withholding anticoagulation in patients at high risk of thrombosis.

    View details for DOI 10.1016/j.gie.2006.02.030

    View details for Web of Science ID 000238766600019

    View details for PubMedID 16813811

  • Absence of ischemia in telangiectasias of chronic radiation proctopathy ENDOSCOPY Friedland, S., Benaron, D., Maxim, P., Parachikov, I., Soetikno, R. 2006; 38 (5): 488-492


    It has been postulated that chronic radiation proctopathy, clinically manifested by hematochezia and by the appearance of multiple telangiectasias, is caused by ischemia. This theory is based on reports that appeared in the 1980s which described obliterative endarteritis in patients with chronic radiation-induced ulcers. However, bleeding from radiation proctopathy is typically successfully treated endoscopically by widespread tissue coagulation, and the complications that would be expected to occur if the tissue was ischemic, such as poor wound healing, generally do not arise. We therefore hypothesized that the ischemia theory is incorrect and that rectal capillary oxygen saturation is normal in patients with telangiectasias of chronic radiation proctopathy.We developed a visible-light spectroscopy device that measures mucosal capillary hemoglobin oxygen saturation during endoscopy (having reported its operating characteristics previously). We prospectively studied 20 patients who had typical findings of multiple rectal telangiectasias, 1 - 20 years after undergoing external-beam irradiation for prostate or rectal carcinoma. We measured and compared the mucosal capillary oxygen saturations in the affected areas of the distal rectum and in endoscopically normal areas in the rectosigmoid colon.Mucosal oxygenation was normal in all 20 patients in affected areas (64 % - 80 %) and in unaffected areas (63 % - 75 %). The mean mucosal hemoglobin oxygen saturation was actually slightly higher in the affected areas of the rectum than in the uninvolved rectosigmoid colon (73 % vs. 69 %, P < 0.01).The common form of chronic radiation proctopathy, characterized by multiple telangiectasias without ulcers or strictures, is not associated with ongoing mucosal ischemia. This finding may explain why endoscopic treatment of this disorder, in which large areas of the mucosa are coagulated with argon plasma or other treatment modalities that cause widespread ulceration, does not typically result in complications from poor wound healing.

    View details for DOI 10.1055/s-2005-921175

    View details for Web of Science ID 000237922000009

    View details for PubMedID 16767584

  • Clipping for upper gastrointestinal bleeding AMERICAN JOURNAL OF GASTROENTEROLOGY Kaltenbach, T., Friedland, S., Barro, J., Soetikno, R. 2006; 101 (5): 915-918
  • Colonic Mucosal Resection of Significant (> 1 cm) Sessile and Non-Polypoid Colorectal Neoplasms: Long Term Experience of a United States Endoscopy Unit. Tonya Kaltenbach, Anamika Maheshwari, Daniel Ouyang, Shai Friedland, Roy Soetikno Division of Gastroenterology, Veterans Affairs Palo Alto Health Care System, Stanford University School of Medicine, Stanford CA Kaltenbach, T., Maheshwari, A., Ouyang, D., Friedland, S., Soetikno, R. MOSBY-ELSEVIER. 2006: AB203-AB203
  • Nonpolypoid (flat and depressed) colorectal neoplasms GASTROENTEROLOGY Soetikno, R., Friedland, S., Kaltenbach, T., Chayama, K., Tanaka, S. 2006; 130 (2): 566-576

    View details for DOI 10.1053/j.gastro.2005.12.006

    View details for Web of Science ID 000235525700029

    View details for PubMedID 16472608

  • Design of a visible-light spectroscopy clinical tissue oximeter JOURNAL OF BIOMEDICAL OPTICS Benaron, D. A., Parachikov, I. H., Cheong, W. F., Friedland, S., Rubinsky, B. E., Otten, D. M., Liu, F. W., Levinson, C. J., Murphy, A. L., Price, J. W., Talmi, Y., Weersing, J. P., Duckworth, J. L., Horchner, U. B., Kermit, E. L. 2005; 10 (4)


    We develop a clinical visible-light spectroscopy (VLS) tissue oximeter. Unlike currently approved near-infrared spectroscopy (NIRS) or pulse oximetry (SpO2%), VLS relies on locally absorbed, shallow-penetrating visible light (475 to 625 nm) for the monitoring of microvascular hemoglobin oxygen saturation (StO2%), allowing incorporation into therapeutic catheters and probes. A range of probes is developed, including noncontact wands, invasive catheters, and penetrating needles with injection ports. Data are collected from: 1. probes, standards, and reference solutions to optimize each component; 2. ex vivo hemoglobin solutions analyzed for StO2% and pO2 during deoxygenation; and 3. human subject skin and mucosal tissue surfaces. Results show that differential VLS allows extraction of features and minimization of scattering effects, in vitro VLS oximetry reproduces the expected sigmoid hemoglobin binding curve, and in vivo VLS spectroscopy of human tissue allows for real-time monitoring (e.g., gastrointestinal mucosal saturation 69+/-4%, n=804; gastrointestinal tumor saturation 45+/-23%, n=14; and p<0.0001), with reproducible values and small standard deviations (SDs) in normal tissues. FDA approved VLS systems began shipping earlier this year. We conclude that VLS is suitable for the real-time collection of spectroscopic and oximetric data from human tissues, and that a VLS oximeter has application to the monitoring of localized subsurface hemoglobin oxygen saturation in the microvascular tissue spaces of human subjects.

    View details for DOI 10.1117/1.1979504

    View details for Web of Science ID 000232799200015

    View details for PubMedID 16178639

  • Optical detection of tumors in vivo by visible light tissue oximetry TECHNOLOGY IN CANCER RESEARCH & TREATMENT Maxim, P. G., Carson, J. J., Benaron, D. A., Loo, B. W., Xing, L., Boyer, A. L., Friedland, S. 2005; 4 (3): 227-234


    Endoscopy is a standard procedure for identifying tumors in patients suspected of having gastrointestinal (G.I.) cancer. The early detection of G.I. neoplasms during endoscopy is currently made by a subjective visual inspection that relies to a high degree on the experience of the examiner. This process can be difficult and unreliable, as tumor lesions may be visually indistinguishable from benign inflammatory conditions and the surrounding mucosa. In this study, we evaluated the ability of local ischemia detection using visible light spectroscopy (VLS) to differentiate neoplastic from normal tissue based on capillary tissue oxygenation during endoscopy. Real-time data were collected (i) from human subjects (N = 34) monitored at various sites during endoscopy (enteric mucosa, malignant, and abnormal tissue such as polyps) and (ii) murine animal subjects with human tumor xenografts. Tissue oximetry in human subjects during endoscopy revealed a tissue oxygenation (StO2%, mean +/- SD) of 46 +/- 22% in tumors, which was significantly lower than for normal mucosal oxygenation (72 +/- 4%; P < or = 0.0001). No difference in tissue oxygenation was observed between normal and non-tumor abnormal tissues (P = N.S.). Similarly, VLS tissue oximetry for murine tumors revealed a mean local tumor oxygenation of 45% in LNCaP, 50% in M21, and 24% in SCCVII tumors, all significantly lower than normal muscle tissue (74%, P < 0.001). These results were further substantiated by positive controls, where a rapid real-time drop in tumor oxygenation was measured during local ischemia induced by clamping or epinephrine. We conclude that VLS tissue oximetry can distinguish neoplastic tissue from normal tissue with a high specificity (though a low sensitivity), potentially aiding the endoscopic detection of gastrointestinal tumors.

    View details for Web of Science ID 000229787600001

    View details for PubMedID 15896077

  • 18-fluorodeoxyglucose positron emission tomography has limited sensitivity for colonic adenoma and early stage colon cancer GASTROINTESTINAL ENDOSCOPY Friedland, S., Soetikno, R., Carlisle, M., Taur, A., Kaltenbach, T., Segall, G. 2005; 61 (3): 395-400


    18-Fluorodeoxyglucose positron emission tomography (PET) is used clinically to detect recurrent colon cancer after surgical resection, but the sensitivity of PET for premalignant colon lesions and early stage colon cancer is not well defined.In a prospective study, 45 patients with a total of 58 colonic neoplasms, including premalignant polyps, premalignant, flat lesions, and early stage cancers, were evaluated by PET.The sensitivity of PET for cancer was 62% (8/13). PET detected 100% (7/7) of cancers 2 cm or larger but only 17% (1/6) of cancers smaller than 2 cm. PET detected 23% (3/13) of flat, premalignant lesions; 70% (7/10) of protruded, premalignant lesions 3 cm or larger; 38% (3/8) of protruded, premalignant lesions between 2 and 2.9 cm; and 14% (2/14) of protruded, premalignant lesions between 1 and 1.9 cm. There was no false-positive PET reading.PET has limited sensitivity for flat, premalignant lesions; protruded, premalignant lesions smaller than 3 cm; and colon cancers smaller than 2 cm.

    View details for Web of Science ID 000227861300008

    View details for PubMedID 15758910

  • Reflectance spectrophotometry for the assessment of mucosal perfusion in the gastrointestinal tract. Gastrointestinal endoscopy clinics of North America Friedland, S., Soetikno, R., Benaron, D. 2004; 14 (3): 539-?


    Reflectance spectrophotometry (RS) is an optical technology that has been used for nearly three decades in the measurement of tissue hemoglobin oxygen saturation in the gastrointestinal tract. The technology has evolved substantially throughout this period,and commercial devices are now available for use in clinical trials. Numerous studies have used RS to investigate the importance of mucosal perfusion in disorders such as ulcer disease, portal hypertension, and septic shock. More recently, the technique has been applied to measure changes in perfusion in response to infusion of vasoactive medications and maneuvers such as cardiopulmonary bypass. The results of current trials investigating the application of RS in critical care monitoring and vascular interventions will likely determine whether the technique will evolve from predominantly a research tool to a clinically useful device.

    View details for PubMedID 15261201

  • Continuous, noninvasive, and localized microvascular tissue oximetry using visible light spectroscopy ANESTHESIOLOGY Benaron, D. A., Parachikov, I. H., Friedland, S., Soetikno, R., Brock-Utne, J., van der Starre, P. J., Nezhat, C., Terris, M. K., Maxim, P. G., Carson, J. J., Razavi, M. K., Gladstone, H. B., Fincher, E. F., Hsu, C. P., Clark, F. L., Cheong, W. F., Duckworth, J. L., Stevenson, D. K. 2004; 100 (6): 1469-1475


    The authors evaluated the ability of visible light spectroscopy (VLS) oximetry to detect hypoxemia and ischemia in human and animal subjects. Unlike near-infrared spectroscopy or pulse oximetry (SpO2), VLS tissue oximetry uses shallow-penetrating visible light to measure microvascular hemoglobin oxygen saturation (StO2) in small, thin tissue volumes.In pigs, StO2 was measured in muscle and enteric mucosa during normoxia, hypoxemia (SpO2 = 40-96%), and ischemia (occlusion, arrest). In patients, StO2 was measured in skin, muscle, and oral/enteric mucosa during normoxia, hypoxemia (SpO2 = 60-99%), and ischemia (occlusion, compression, ventricular fibrillation).In pigs, normoxic StO2 was 71 +/- 4% (mean +/- SD), without differences between sites, and decreased during hypoxemia (muscle, 11 +/- 6%; P < 0.001) and ischemia (colon, 31 +/- 11%; P < 0.001). In patients, mean normoxic StO2 ranged from 68 to 77% at different sites (733 measures, 111 subjects); for each noninvasive site except skin, variance between subjects was low (e.g., colon, 69% +/- 4%, 40 subjects; buccal, 77% +/- 3%, 21 subjects). During hypoxemia, StO2 correlated with SpO2 (animals, r2 = 0.98; humans, r2 = 0.87). During ischemia, StO2 initially decreased at -1.3 +/- 0.2%/s and decreased to zero in 3-9 min (r2 = 0.94). Ischemia was distinguished from normoxia and hypoxemia by a widened pulse/VLS saturation difference (Delta < 30% during normoxia or hypoxemia vs. Delta > 35% during ischemia).VLS oximetry provides a continuous, noninvasive, and localized measurement of the StO2, sensitive to hypoxemia, regional, and global ischemia. The reproducible and narrow StO2 normal range for oral/enteric mucosa supports use of this site as an accessible and reliable reference point for the VLS monitoring of systemic flow.

    View details for Web of Science ID 000221551300018

    View details for PubMedID 15166566

  • Ligate and let go GASTROINTESTINAL ENDOSCOPY Friedland, S., Kahng, L. S., Torosis, J., Soetikno, R. M. 2003; 58 (3): 473-474

    View details for Web of Science ID 000185132500039

    View details for PubMedID 14528239

  • Measurement of mucosal capillary hemoglobin oxygen saturation in the colon by reflectance spectrophotometry GASTROINTESTINAL ENDOSCOPY Friedland, S., Benaron, D., Parachikov, I., Soetikno, R. 2003; 57 (4): 492-497


    Advances in optical and computer technology have enabled the development of a device that uses white-light reflectance spectrophotometry to measure capillary hemoglobin saturation in intestinal mucosa during colonoscopy.Studies were performed with the colon oximeter in anesthetized animals and patients undergoing colonoscopy.Mean (SD) mucosal hemoglobin saturation in the normal colon was 72% (3.5%). In an animal model, ischemia induced by arterial ligation and hypoxemia via hypoxic ventilation each resulted in a decrease of over 40% in the mucosal saturation. In patients with colon polyps, ischemia induced by epinephrine injection, stalk ligation with a loop, or clipping of the polyp stalk each resulted in a decrease of over 40% in the mucosal saturation (p < 0.02). In contrast, saline solution injection did not decrease the mucosal saturation.A novel device for measuring capillary hemoglobin saturation in intestinal mucosa during colonoscopy is capable of providing reproducible measurements in normal patients and clearly detects dramatic decreases in saturation with ischemic and hypoxic insults.

    View details for DOI 10.1067/mge.2003.162

    View details for Web of Science ID 000182004400009

    View details for PubMedID 12665758

  • Quantitative clinical non-pulsatile and localized visible light oximeter: Design of the T-Stat (TM) tissue oximeter OPTICAL TOMOGRAPHY AND SPECTROSCOPY OF TISSUE V Benaron, D. A., Parachikov, I. H., Cheong, W. F., Friedland, S., Duckworth, J. L., Otten, D. A., Rubinsky, B. E., Horchner, U. B., Kermit, E. L. 2003; 4955: 355-368
  • Measurement of mucosal capillary hemoglobin oxygen saturation in the colon by reflectance spectrophotometry LASERS IN SURGERY: ADVANCED CHARACTERIZATION, THERAPEUTICS, AND SYSTEMS XIII Friedland, S., Benaron, D., Parachikov, I., Soetikno, R. 2003; 4949: 405-412
  • Gastric pancreatic rest leading to pyogenic liver abscess GASTROINTESTINAL ENDOSCOPY Friedland, S., Yu, A., Rouse, R. V., Wong, D., Nino-Murcia, M., Soetikno, R. M. 2002; 56 (3): 438-440

    View details for DOI 10.1067/mge.2002.126619

    View details for Web of Science ID 000177775800026

    View details for PubMedID 12196792

  • Bedside scoring system to predict the risk of developing pancreatitis following ERCP ENDOSCOPY Friedland, S., Soetikno, R. M., Vandervoort, J., Montes, H., Tham, T., Carr-Locke, D. L. 2002; 34 (6): 483-488


    Pancreatitis is the most common significant complication of endoscopic retrograde cholangiopancreatography (ERCP). The aim of the present study was to develop a simple scoring system that clinicians can use to predict the risk of post-ERCP pancreatitis.We analyzed a prospectively assembled database of 1835 ERCP procedures at a single referral hospital. Multivariate logistic regression analysis was performed to identify risk factors for pancreatitis and determine their relative contributions. From these results, a scoring system was constructed. The performance of the scoring system was assessed on the entire procedure database and in selected subgroups.Multivariate analysis yielded four risk factors: pain during the procedure, cannulation of the pancreatic duct (PD), previous post-ERCP pancreatitis, and number of cannulation attempts. Based on the regression model, the scoring system was: 4 points for pain, 3 points for PD cannulation, 2 points for a history of post-ERCP pancreatitis, and 1 - 4 points depending on the number of cannulation attempts. A total score of 1 - 4 points was associated with a low risk of pancreatitis (< 2 %), while a score of 5 - 8 points had an intermediate risk (7 %), and a score of 9 or above had a high risk (28 %).This simple scoring system may enable clinicians to stratify patients into low-risk, medium-risk, and high-risk groups for the development of post-ERCP pancreatitis. In addition, when patients with suspected sphincter of Oddi dysfunction and patients who underwent minor papilla cannulation were analyzed separately, the scoring system was able to predict accurately the pancreatitis risk of these patients as well.

    View details for Web of Science ID 000176079300011

    View details for PubMedID 12048633

  • Preoperative evaluation of submucosal invasive colorectal cancer using a 15-MHZ ultrasound miniprobe. Gastrointestinal endoscopy Friedland, S., Soetikno, R. 2002; 55 (7): 959-961

    View details for PubMedID 12024172

  • A novel method to control severe upper GI bleeding from metastatic cancer with a hemostatic sealant: the CoStasis surgical hemostat GASTROINTESTINAL ENDOSCOPY Milkes, D. E., Friedland, S., Lin, O. S., Reid, T. R., Soetikno, R. M. 2002; 55 (6): 735-740

    View details for DOI 10.1067/mge.2002.122796

    View details for Web of Science ID 000175455300024

    View details for PubMedID 11979262

  • Placement of esophageal self-expandable metallic stents without fluoroscopy GASTROINTESTINAL ENDOSCOPY Friedland, S., Soetikno, R. 2001; 54 (3): 420-420

    View details for Web of Science ID 000170784600034

    View details for PubMedID 11522998

  • Stenting the sigmoid colon in a terminally ill patient with prostate cancer. Journal of palliative medicine Friedland, S., Hallenbeck, J., Soetikno, R. M. 2001; 4 (2): 153-156


    Large bowel obstruction in the terminally ill patient can be difficult to manage. We describe a patient with sigmoid colon obstruction caused by metastatic prostate cancer in the pelvis who required hospitalization because of severe pain and obstructive symptoms. Treatment with an endoscopically placed self-expandable metal stent allowed the patient to have immediate resolution of symptoms and to receive hospice care at home.

    View details for PubMedID 11441623

  • Lift and ligate: a new technique to treat a bleeding polypectomy stump GASTROINTESTINAL ENDOSCOPY Soetikno, R. M., Friedland, S., Lewit, V., Woodford, S. 2000; 52 (5): 681-683

    View details for Web of Science ID 000165148900021

    View details for PubMedID 11060200

  • Long-term follow-up of patients with chronic hepatitis B: A 25 year prospective study. Cardenas, C. L., Soetikno, R., Robinson, W. S., Merigan, T. C., Gregory, P. B., Friedland, S., Kwan, J., Garcia, G. WILEY-BLACKWELL. 1999: 300A-300A

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