Stricture Management - Cook Medical

The Channel
A COOK NEWS PUBLICATION ISSUE 2, 2009
Advancing the Science of
Stricture Management
Gregory Haber, MD, FRCPC
Director of Gastroenterology
Lenox Hill Hospital
New York, NY
DDW 2009 Stricture Management Symposium
“This is going to be a terrific learning
experience for all of us this evening,” said Dr.
Gregory Haber at the beginning of the “Advances
in Stricture Management” symposium, which he
moderated at DDW 2009. “Cook Medical has put together
a stellar group of faculty to talk about stricture management.”
The evening featured presentations by Professor Nageshwar
Reddy (“Longer Patency: An Alternative to Biliary SEMS: Comparative
Study Results”), Professor Horst Neuhaus (“Biliary SEMS: What’s New and
What’s on the Horizon”), Professor Alessandro Repici (“Stricture Management:
Clinical Experience and Results of a New Stent Platform”) and Professor Guido
Costamagna (“Magnetic Anastomosis: A Non-Surgical Alternative: Human
Experience to Date”).
The event, sponsored by Cook Medical, was held at the Sheraton Chicago Hotel & Towers.
Aimed at increasing awareness of advances and solutions in stricture management, the
symposium drew approximately 300 participants.
The editors of The Channel recently spoke with Dr. Haber and asked him to step out of his moderator’s
role and share some of his observations and insights (below) on the “Advances in Stricture Management”
symposium. We also asked Dr. Haber to reflect on each member of the expert panel (see page 4).
ADVANCING THE SCIENCE OF STRICTURE MANAGEMENT Continued on page 2
INSIDE THIS ISSUE
MD FOCUS 2
REFLECTING ON THE PRESENTERS 4
2ND INTERNATIONAL FUSION
WORKSHOP IN MARSEILLES
DR. LEUNG ON FUSION TITAN 6
NEW MARSHA DREYER AWARD 8
UNIVERSITY OF KENTUCKY
SHOULDERING SOCIAL
RESPONSIBILITY
CHANGING LIVES - AN
ECUADORIAN MISSION TRIP
SUCCESSFUL BILATERAL PLACEMENT
OF ZILVER 635 BILIARY STENTS
DR. PARSONS AND NORTHWEST
COMMUNITY HOSPITAL DAZZLE
ATTENDEES IN THE “CITY OF LIGHTS”
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10
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WHAT’S UP DOC? 14
NEXT GENERATION FUSION OMNI 14
DR. PETER DRAGANOV LEADS
EUS COURSE
NEW SERRATED CAPTURA FORCEPS
ON THE CUTTING EDGE OF
OPTIMAL SAMPLING
5TH ANNUAL CRYSTAL
AWARDS GALA
MEMORY SERVES US WELL IN
CHINA - A CASE REPORT
NEWS FROM SIGNEA - ESOPHAGEAL
CANCER EARLY WARNING SIGNS
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GI360 20

Gregory Haber, MD, FRCPC
Director of Gastroenterology
Center for Advanced
Therapeutic Endoscopy
Lenox Hill Hospital
New York, NY
Dr. Gregory Haber graduated with a
degree in Medicine from the University
of Toronto and completed his specialty
training in Internal Medicine in 1975 and
Gastroenterology in 1978. His first position
after training was as a researcher at the
University of Bristol where he studied bile
acid metabolism, having received a Medical
Research Council of Canada grant for this
endeavor. Two years later he returned to the
University of Toronto, as a faculty member in
the Division of Gastroenterology.
He served on the staff of The Wellesley
Hospital and St. Michael’s Hospital, University
of Toronto, for 25 years, and is currently the
Director, Division of Gastroenterology
and Director of the Center for Advanced
Therapeutic Endosocpy at Lenox Hill
Hospital in New York.
One of the world’s foremost experts on
the treatment of digestive diseases and a
prolific researcher, he has published over
50 peer-reviewed articles, and numerous
abstracts. His research has been funded
by numerous peer-reviewed agencies, and
the pharmaceutical and medical device
industries. Dr. Haber has spoken as invited
faculty at over 200 scientific meetings. He
was an associate editor of Gastrointestinal
Endoscopy, as well as a member of the
board of Endoscopy and Techniques in
Gastrointestinal Endoscopy.
2
www.cookmedical.com
Q: What attracted you to the idea of moderating the
“Stricture Management” symposium?
Dr. Haber: My personal interest is based on a lifelong clinical career, growing up with selfexpanding
metal stents in transition from plastic stents. It has been interesting to observe
the evolution of stent technology and the engineering that has gone into perfecting them.
The symposium helped put into perspective the use of SEMS in terms of mature, thoughtful
practices. These are all matters of great interest to me.
Q: Take off your
moderator hat and
become an audience
member, and tell us
your impressions.
Dr. Haber: The event was very
well designed and executed.
Cook Medical brought together
some of the finest teachers
in the world. We could not
have had a more impactful
group of guys presenting at a
symposium. Their presentations
bridged new areas of investigations and how these impact on new avenues of therapeutics.
The speakers are innovators and practitioners, incorporating the newer, novel therapies
into clinical practice. It was fascinating to see the clinical outcomes that were associated
with these new and enhanced stricture management solutions and the clinical scenarios
that were addressed. These were put into perspective with the established therapies and
how they are most appropriately applied to complex problems.
Everyone was very positive and the event garnered high compliments for Cook Medical.
Q: What would you say were the most
important takeaways from the symposium?
Dr. Haber: This symposium vividly illustrated that we currently have an enormous range of
available technologies to help us solve the clinical problems and challenges we face. While
new developments have made endoscopic therapeutic intervention easier and easier and
more widely applicable and available, more solutions are needed. One of the challenges
discussed was choosing which option is most appropriate at a particular point of time as
the disease manifests in the patient.
I think everyone at the symposium picked up some practical points as to how to use new
and enhanced techniques and methods in their practice.
Q: Regarding plastic vs. metal stenting*: What factors,
aside from clinical outcomes, are making the choice
between plastic and metal stents challenging?
Dr. Haber: I think the major ongoing challenge in the “plastic versus metal” debate is trying
to create validated predictors of survival rates that will help the endoscopist choose the
therapy most appropriate for that length of survival.
Another major determinant in deciding whether one uses plastic or metal stents is clearly
the economic factor. In third-world countries and countries with diminishing resources,
the economic factor plays a much more important role.
*Plastic stents are used to drain obstructed biliary ducts. Metal stents are used in the palliation of malignant
neoplasms in the biliary tree.

Q: Given the current economic pressures in the U.S.,
do you think that physicians will be asked more
and more to justify their choices?
Dr. Haber: Everyone has to become more tuned in and sensitized to the economic
impact of therapeutic choices. That’s why it is very helpful at a symposium like this
for the endoscopist to be able to get a sense of what stricture management
choice is most appropriate and not just place the same stent into every
patient, regardless of cost or need. I think the symposium also showed
that in spite of the advances in SEMS, there is still an important role
for plastic stenting. In certain countries, due to limited resources
and inability to supply metal stents, not only is plastic stenting
appropriate in certain patients but it may be the only choice.
Q: What opportunities to solve
clinical problems do you see with
the 6 French Zilver?
Dr. Haber: The deployment system of the 6 French
Zilver is definitely a quantum leap forward. It changes
the whole playing field for bilateral multiple stenting
with its ability to place two or more metal stents in the
bifurcation or for hilar obstruction. The key is its ability to
place stents simultaneously and to ensure the stents are
side-by-side, especially at the distal ends. That’s definitely
a huge step forward. That will change practices in terms of
hilar stenting. We will see more and more of those procedures
going forward.
Q: What do you feel are the big opportunities to
solve clinical problems with the Fusion Marathon*?
In your opinion, do you think further study
results will be needed to gage the potential
of that device?
Dr. Haber: The results of the nonrandom trial looked very good.
But I think a prospective randomized controlled multicenter trial
in North America will go a long way toward making it a standard
of care as opposed to an attractive option. There’s no question
that such a study would be a big boon in jumpstarting
widespread use. I think that even without a trial, it is likely to
be implemented but at a slower pace as practitioners
garner experience at individual sites.
Q: Do you have any other thoughts on the
symposium you would like to share?
Dr. Haber: I thought the event was one of the best-run evening symposia that I’ve been
involved with. The venue was excellent and the atmosphere was relaxed. It was a great
format for our expert panel to share their expertise with the audience.
*The Fusion Marathon stent is intended for endoscopic placement of a preloaded biliary stent to drain obstructed
biliary ducts and reduce duodenal content reflux.
The Channel
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3

4 www.cookmedical.com
Reflecting on the Presenters
of “Advances in Stricture Management”
Moderator Dr. Gregory Haber recently shared his
thoughts on each of the expert symposium presenters
Nageshwar D. Reddy, MD
Director of the Asian Institute of Gastroenterology
Professor, Owasis Medical College
Hyderabad, India
“Professor Reddy is one of the most experienced pancreatobiliary endoscopists in the world. Because
of the demographics of India, where he works, he treats a very large population of specific types
of disease, especially chronic pancreatic stone disease, as well as unusual biliary tract problems
related to various parasitic worms, etc. In India the impact of economic restraints is a daily reality
necessitating the best use of technology within a fiscal perspective. It’s been very interesting to
see where he is going with that. At the symposium, it was great to hear from somebody who has
so much clinical experience reflect on his past and look into the future.”
Prof. Horst Neuhaus, MD
Evangelisches Krankenhaus
Medizinische Klinik
Dusseldorf, Germany
“Professor Neuhaus, one of the leading German endoscopists, has gained an international reputation
by traveling to virtually every continent every few months, tracking new developments and new
applications. He has his finger on the pulse of endoscopy as it is practiced around the world. He is
able to not only introduce the new technologies but he is also able to put them into an international
perspective. With his ability to create a stimulating and productive learning environment, Professor
Neuhaus has made a major impact internationally as a teacher of endoscopy. Several years ago, he
began a live endoscopy course in Düsseldorf and, from its humble beginnings of perhaps a couple
of hundred attendees, it has developed a wide following, attracting some 1200 to 1500 attendees
annually. It’s now one of the largest courses, outside of national society meetings, in the world.
So, to have an experienced teacher and practitioner such as Horst share his experiences added
enormously to the talent at the table.”
Alessandro Repici, MD
Director, Department of Digestive Endoscopy
Istituto Clinico Humanitas
Milano, Italy
“I know Dr. Repici very well, going back to early in his career when he spent time with us at the
Wellesley Therapeutic Endoscopy Group in Toronto when I was there. He returned to Italy, where he
was obviously a rising star, emerging as one of the most dynamic, enthusiastic, energetic figures in
Italian therapeutic endoscopy. He has clearly established himself one of the leaders in translational
research, introducing new stent technologies into clinical practices. He has tremendous experience
in enteral stenting in the esophagus, duodenum and colon. He engenders enthusiasm each time he
embarks on clinical trials and enjoys taking on the challenges of new stent design and technology.”
Prof. Guido Costamagna, MD, FACG
Director Digestive Endoscopy Unit
Agostino Gemelli University Polyclinic
Professor of Surgery, Catholic University of the Sacred Heart
Rome, Italy
“There are a handful of leading endoscopists in Europe whom we see around the world at all the major
meetings and Guido is one of them. He came from the Brussels school, trained with Michel Cremer
and went back to Rome and became the preeminent therapeutic endoscopist there. He is known as
a tenacious investigator, directing innovative clinical trials and evaluating new technologies. He is
constantly pushing the envelope in an effort to expand endoscopic therapeutic avenues. Although
he is recognized as a giant in therapeutic endoscopy, he is humble and approachable, a great and
empathetic teacher who understands the challenges that even first-year endoscopists face.”

French Society of Digestive Endoscopy
President Hosts
International
Fusion Workshop
in Marseilles
Gastroenterologists from Slovakia and Croatia journeyed to the southeastern French La Timone
Hospital in Marseilles to learn new endoscopic techniques and hone their skills.
Led by Professor René Laugier – director of gastroenterology, digestive endoscopy and therapeutic
endoscopy at the hospital – the visiting physicians benefited from two days of presentations
and hands-on procedures involving short wire exchange, stenting and endotherapy of chronic
pancreatitis, pancreatic cancer and biliary diseases.
Professor Laugier, a specialist in biliopancreatic diseases and therapeutic endoscopy, currently serves
as President of the French Society of Digestive Endoscopy. At the 1000-bed La Timone Hospital, he
is head of the department of gastroenterology (including endoscopy department) and sees more
than 40 patients per week for consultation and averages two days of diagnostic and therapeutic
endoscopy per week.
Prior to the workshop, Professor Laugier set some ambitious goals, including: demonstrating the
most recent endoscopic procedures, presenting and discussing the latest endoscopic equipment,
examining the advantages and disadvantages of short wire guides and suggesting ways
to reduce bacterial risk in ERCP, as well as reducing the risk of pancreatitis.
A Wide Range of Endoscopic Topics
Professor Laugier offered participants a wide variety of endoscopic topics. “On Thursday
we covered every kind of digestive endoscopy procedure,” he said. “We also presented
a range of Cook endoscopic products, with emphasis on material based on Fusion. This
was followed by more than three hours of videos illustrating all therapeutic endoscopy
techniques as well as hands-on training for developing good technique.”
Topics that Professor Laugier covered included: chronic pancreatitis (pancreatic duct
and main bile duct stenosis, stone destruction and extraction), biliary stenting in
pancreatic cancer, double stenting for hilum strictures, digestive cystostomies and
digestive metal stenting.
On Friday the group was in the operating room from 8 a.m. to 4 p.m. for live cases. “All participants
worked in the endoscopic room, along with nurses, who did great work using Fusion products. We
presented each case, discussed the indications, explained the endotherapy, and commented on
every aspect. This segment involved examining and treating patients with varying pancreatobiliary
or digestive tract illnesses.”
The feedback Professor Laugier received was overwhelmingly positive. “The physicians were highly
pleased and proud to be chosen to attend,” said Professor Laugier. “They heard many technical aspects
and were keen for this kind of education. They learned important details on many aspects, particularly
on how we perform examinations. There were many compliments for the opportunity to participate.”
For the next international workshop, Professor Laugier plans to duplicate the two-day format. “All
feedback indicates this was an appropriate format and length,” he concluded.
The Channel
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5

Joseph Leung, MD, FRCP,
FACP, FACG, FASGE
Mr. and Mrs. C.W. Law Professor of
Medicine, University of California,
Davis School of Medicine, Chief
of Gastroenterology, VA Northern
California Health Care System
Brian Lim, MD, MCR
Gastroenterology
Kaiser Permanente Riverside
Medical Center
(Former gastroenterology
fellow at UC Davis
Medical Center)
6 www.cookmedical.com
pening
p
Balloon dilation of a bile duct stricture facilitates access into the biliary system or beyond the
obstruction for removal of bile duct stones or placement of a biliary stent to provide drainage.
Because of the larger balloon diameter, they are more effective compared to the more rigid
(but much smaller) graded dilation catheters.
Technique of balloon dilation
An overview of
balloon dilation in
the management
of biliary disease
Dilation balloons or biliary balloon dilatation catheters (as some refer to) come
in different sizes and in general, range from 4 to 10 mm in diameter and 2
to 4 cm in length, e.g. Hurricane (Boston Scientific, Natick, MA) or Fusion
Titan Biliary Dilation Balloon (Cook Endoscopy, Winston Salem, NC). They
are mostly made of nylon or polyethylene terephthalate (PET) and are
minimally-compliant balloons. It is recommended to use a regular .035”
wire guide to provide rigidity for effective dilation. The balloon is inserted
over a pre-positioned wire guide placed within the bile duct or across
the bile duct stricture. The two ends of the balloon are indicated by
radiopaque ring markers to help positioning of the balloon across
the stricture (usually with the stricture located at the midpoint of the
balloon for effective dilation). Inflation of the balloon is performed
using a pressure insufflator by injecting diluted contrast to fill the
balloon. The appearance of initial waist formation on the balloon
denotes the level of the obstruction. The balloon is inflated slowly to the
recommended pressure (per manufacturer) and the obliteration of the
waist indicates effective dilation of the stricture/papilla. Depending on
individual physicians, the balloon is kept inflated for between 15 seconds
to a minute to allow proper stretching of the stricture.
Recent improvement to balloon design
The earlier balloons (e.g., Quantum Balloon Dilators) were designed with only
one proximal side-hole (or inflation port) that connects to the balloon, which
allows inflation and deflation of the balloon. However, the limitation to the flow of
contrast (especially for normal or dense contrast) with a single side-hole meant that
the balloon is inflated from the proximal end which often predisposes the balloon to
migration (especially in case with a tight biliary stricture). Proper positioning of the balloon
is maintained sometimes by pulling or pushing on the balloon catheter, especially during early
balloon inflation, to resist its migration. Furthermore, the single side-hole limits return (free flow) of
contrast, making deflation of the balloon more difficult. This happens more often when the partially

Figure 1
Balloon dilation after endoscopic
sphincterotomy to facilitate removal
of CBD stones through a distal bile
duct sricture.
deflated balloon is pulled back into the scope channel, further restricting the return
flow of contrast. A partially deflated balloon makes it more difficult to be withdrawn
into the scope channel and increases the difficulty with wire guide exchange.
Although the use of more diluted contrast is helpful, there are still limitations in rapid
inflation and deflation of the balloon related to a single side-hole.
The new Fusion Titan Biliary Dilation Balloons (Cook Endoscopy, Winston Salem, NC)
have an improved design, which incorporates two sets of side-holes at either end of the
balloon. This design allows efficient insufflation and deflation of the balloon and minimizes
the risk of balloon migration because both sides of the balloon can be inflated, holding it in
position like a “dog-bone appearance,” especially in the case of a tight stricture. Furthermore, the
balloon can be efficiently and completely deflated, making withdrawal of the balloon and subsequent
wire guide exchange more easily without losing the wire position.
Application in bile duct stricture
management and stone extraction
Endoscopic sphincterotomy (ES) is an established treatment for the removal of common bile duct
stones. Removal of stones proximal to a relative distal bile duct narrowing can be challenging. In
order to facilitate stone removal, the bile duct obstruction is dilated before balloon sweep. Although
transient post-dilation bleeding has been reported, surprisingly the incidence of post-dilation
pancreatitis from prolonged balloon dilation has not increased significantly. This however, may be
related to the use of prophylactic pancreatic stenting in some cases to prevent post-ERCP pancreatitis.
Patients with intrahepatic stones pose a challenge to endoscopic removal, and effective dilation
of the associated stricture is necessary to facilitate stone removal. Indeed, the persistence of waist
formation on the balloon despite full insufflation would signify difficulties in removing the stone(s)
without resorting to lithotripsy. The Fusion Titan Balloon, which resists migration during insufflation,
is more effective in dilating the intrahepatic stricture.
Application in bile duct strictures
In the management of patients with malignant biliary obstruction or benign post-operative bile duct
strictures such as post liver transplantation, balloon dilation facilitates the placement of biliary stents
for drainage. In the case of post-surgical changes, we recommend initial stenting for drainage only
without any balloon dilation until the injury or stricture is set. We usually wait three months before
contemplating balloon dilation of the stricture. Insertion of multiple biliary stents is technically
difficult although, when successful, provides more effective drainage as well as splinting for the
stricture. In choosing the right size balloon, it is important to assess the diameter of the normal
part of the bile duct (usually the distal CBD below the level of the obstruction). Excess balloon size
poses a risk of perforation from overzealous balloon dilation. The placement of multiple stents can
be facilitated using the Fusion OASIS system (Cook Endoscopy, Winston Salem, NC), which allows
intraductal exchange of the wire guide above the obstruction thus maintaining access across the bile
duct stricture after initial stent deployment. This allows subsequent double or triple stent placement
without having to recannulate or renegotiate the stricture.
The Channel
a
b
c
d
Figure 2a - b
Multiple biliary
stenting using
the Fusion OASIS
after balloon
dilation of CHD
stricture.
Figure 3
a. Balloon with simulated stricture (O-ring).
Note radiopaque ring markers (large arrows)
on either end of the balloon and side-holes
(small arrows).
b. Partial filling of the balloon. Note that the
proximal half of the balloon is filling first
but the distal portion also fills, keeping the
balloon (waist formation) in a stable position
in relation to the stricture.
c. Complete obliteration of the waist.
d. Rapid collapse of the balloon on either side
of the stricture upon deflation.
www.cookmedical.com
7

Fig A
Fig B
A 75-year-old patient
presents with 10 days
of painless jaundice and
itching. On abdominal
examination the patient has
a fluctuant mass palpable
below the right costal
margin in the midclavicular
line. The resident who
examines him describes
Dr John Baillie
the “mass” as feeling like
a “rubber ball” that he can “bounce” under
his fingers, but he can’t get above it. He
suggests a diagnosis, which is supported by
an abdominal CT scan (Figs A and B).
What structure is the resident
feeling on abdominal palpation?
What abnormalities are
present on the CT scan?
What diagnosis did the resident
suggest to explain (unify) all the
findings? Whose “sign” is present?
What endoscopic intervention
will help this patient?
To confirm your diagnosis, click on
newsletter button on endoscopy homepage
of www.cookmedical.com
We are looking for more submissions and
welcome your participation. If you want to
submit an image with a written case history
and clinical explanation, please contact Kevin
Chmura at kevin.chmura@cookmedical.com.
8 www.cookmedical.com
Cook Medical and ASGE Announce New
AWARD
At the 2009 Crystal Awards Dinner in Chicago, Cook Medical Endoscopy division
President Bill Gibbons and the ASGE announced the newly established Marsha
Dreyer Award. The award will pay travel expenses for up to three international trainee
members’ (up to $4,500) to attend Digestive Disease Week® beginning in 2010.
Introducing the award, Gibbons said,
“For more than three decades, Marsha worked alongside some
of the leading gastroenterologists in the world. And, fortunately for us,
Marsha was driven to share that knowledge with all who were willing to
learn from her through her passionate commitment to continuing education
opportunities for GI professionals around the globe. So, in a fitting tribute to
Marsha, today we are proud to announce that her commitment and
her passion will live on with the Marsha Dreyer Award.”
ASGE’s International Committee will review the applications and make
recommendations to the ASGE Governing Board, which will make the final selections.
Priority will be given to applicants who would otherwise not be able to attend DDW.
To be eligible for the Marsha Dreyer Award, applicants must:
1. Be a current ASGE international trainee member
within five years of completing training.
2. Be first or submitting author of a DDW 2010
abstract. Case reports are not eligible.
In order for abstracts to be considered for the award, the Cook Medical Marsha Dreyer
Award checkbox must be marked on the DDW abstract submission application.
There will be three awards selected from approved DDW 2010 abstracts. The
abstracts must be submitted by Tuesday, December 1, 2009 to DDW (visit www.ddw.
org regarding abstract submissions). Late submissions will not be considered. For
additional information please contact Holly Becker, Manager of International Member
Relations, American Society for Gastrointestinal Endoscopy, 1520 Kensington Road,
Suite 202, Oak Brook, IL 60523; phone: 630-570-5631; fax 630-573-0691; or email
hbecker@asge.org.

Expand your procedural possibilities.
When facing challenging biliary stenting procedures, sometimes you have to
think small. With the market’s smallest introducer and coil-reinforced
construction, the new Zilver 635 opens up your procedural possibilities. For
instance, the Zilver 635 is the only introducer in the world that allows you to
simultaneously place and align two metal stents at the bifurcation. By combining
the latest in access capability and the proven benefits of Zilver, the 635 is sure
to advance the field of biliary stenting.
Contact your Cook Medical representative or visit www.cookmedical.com for
more information about the Zilver 635 Biliary Self-Expanding Stent.
Cook Medical – Delivering the clinical advantage.
AORTIC
INTERVENTION
CARDIOLOGY
CRITICAL
CARE
ENDOSCOPY
INTERVENTIONAL
RADIOLOGY
PERIPHERAL
INTERVENTION
Warning: The safety and effectiveness of
this device for use in the vascular system
has not been established.
SURGERY UROLOGY
WOMEN’S
HEALTH
© COOK 2009
Image Courtesy of Dr. Terruzzi Vittorio & Dr. Radaelli Franco, Ospedale Valduce Como, Italy

University of
Kentucky
Shouldering
Social
Responsibility
For more than a decade, medical teams from Kentucky have served
health needs in Ecuador. Shoulder to Shoulder Ecuador (STSE) was
established by Dr. Tom Young, professor of pediatrics, UK College
of Medicine, along with Lexington, KY community partners. STSE is
based in Kentucky and works in partnership with Hombro a Hombro
Ecuador in Santo Domingo to improve the health and lives of children
and their families.
Over the years, the university has established strong relationships in
Quito and Santo Domingo. Through a series of community meetings
in Santo Domingo, community leaders identified Carlos Ruiz Burneo
(population 20,000) as an area of extreme poverty in dire need of
access to medical care.
April 2007 marked the opening of Centro Medico Hombro a Hombro
in Carlos Ruiz Burneo. Physicians, nurses, a dentist and support staff
operate the primary care center there. Since the opening, the center
has treated more than 3,000 new patients. Services include:
Primary medical care Public health programs
School health Feeding programs for
programs infants and mothers
Gastroenterology services Dental services
Cancer screenings
Tom Young, MD,
Professor of Pediatrics,
UK College of Medicine
Also at the University of Kentucky, Medical Mission Ecuador – led by
Dr. Henry Vasconez, professor of surgery and chief of plastic surgery,
UK College of Medicine – has provided medical and surgical services
to Ambato, Ecuador for many years. For example, during the past five
years, UK’s Department of Pediatrics led pediatric teams to Ecuador
with faculty, residents and students. UK has a formal relationship
with the PUCE Medical School in Quito for the exchange of faculty
and students.
Partners and supporters of STSE and MME include the University
of Kentucky (UK), Cathedral of Christ the King, UK International
Federation of Medical Students Association (IFMSA), UK STSE Student
Association, Josephson Foundation, Kiwanis Club of Lexington,
UK Newman Center, Kroger, LexAir, Inc., Jubileo Foundation, and
community volunteers. In Ecuador, the Kiwanis Club of Santo
Domingo and FASCA (a Catholic social service agency) are partners.
10 www.cookmedical.com
and
perspectives
An Ecuadorian mission trip
Nicholas J. Nickl, MD,
Professor of Medicine,
University of Kentucky HealthCare
“Should you have an opportunity to serve
humanity this way,” says gastroenterologist
Nicholas J. Nickl, “take it! The experience will
change the lives of the people you treat. And
it will change your life.”
The experience that Dr. Nickl – Professor
of Medicine at the University of Kentucky
HealthCare – is referring to is the medical
mission he took to an impoverished area of
Ecuador in August 2008.
Dr. Nickl – along with endoscopist Luis
R, Pena, MD, and endoscopic nurse Betsy
Matthews, RN, both also from the university’s
GI division – joined a team of other healthcare
professionals and traveled to Santo Domingo,
a city three hours west of Ecuador’s capital
Quito. Healthcare services provided by the
group included family practice, pediatrics,
dental, nursing and gastroenterology.
The group worked at an indigent barrio
clinic founded and run jointly by Shoulder
to Shoulder Ecuador, the University of
Kentucky and the Roman Catholic
diocese of Santo Domingo. (See sidebar:
“University of Kentucky: Shouldering Social
Responsibility”). Dr. Nickl also lent a hand
at Gustavo Dominguez Hospital, where he
treated the digestive health needs of 21
patients. “During this mission, I saw patients
with gastritis, several cases of H pylori
infection and some serious reflux diseases.
All patients had some significant digestive
healthcare needs.”
Providing “the best
healthcare available”
Dr. Nickl is especially proud that the team
was able to care so well for people who had
so little. “It felt good to provide the best
healthcare available. We made no quality
compromises and used the same state-ofthe-art
equipment and procedures we have
in the U.S. In fact, it was as good as any place
in the world.”

The people that he met and treated have
left a lasting impression on Dr. Nickl. “They
were so sweet, friendly and grateful for the
healthcare. I recall one patient who was so
excited to see a North American GI professor
that he walked to the clinic in his Sunday
best clothing. Suddenly, these heretofore
faceless people became familiar faces. They
are wonderful people who love their children.
They were no longer just stereotyped images
we had of South Americans. The people we
met were open to North Americans. They do
not think of us as heartless.”
International politics were not a concern
for the mission team. “Ecuador is a stable
democracy,” says Dr. Nickl. “They use the U.S.
dollar as their currency.”
More trips to Ecuador to come
This was the second trip to Ecuador for Dr.
Nickl. In July 2007, he was part of a churchsponsored
Habitat for Humanity group.
At that time, the Centro Medico Hombro
a Hombro in Carlos Ruiz Burneo was just
getting started and Nickl and his medical
colleagues treated many of its first patients.
“That 2007 trip and last year’s trip have given
me new perspectives on all the privileges we
have in our country,” says Dr. Nickl. “We cannot
ignore these people and their needs.” Dr. Nickl
plans to return to Ecuador this summer (2009)
and he is planning an eight-month sabbatical
there in 2010.
“It is all about helping people.”
The August 2008 mission to Ecuador was
sponsored primarily by the University of
Kentucky Medical Center as well as other
charities, including the Roman Catholic
Cathedral of Christ the King church in
Lexington. Each member of the team paid
his or her own way and used vacation time
to make the trip. Shoulder to Shoulder
Ecuador is an independent group consisting
of members of the University of Kentucky
medical community, which provides
administrative and fundraising assistance to
support the Hombro a Hombro Clinic.
Healthcare
Ecuador
in
Total population: 13,200,000
The Channel
Life expectancy at birth (years): Men 70, Women 76
Probability of dying before age five: (per 1,000 live births) 24
Total expenditure on health per capita: $297
Total expenditure on health as a % of gross
domestic product: 5.4%
Top ten causes of death, all ages:
Ischemic heart disease Cerebrovascular disease
Diabetes mellitus Lower respiratory infections
Hypertensive heart disease Tuberculosis
Parinatal conditions Violence
Stomach cancer Nephritis and nephrosis
Source: World Health Organization, 2006
www.cookmedical.com
11

12 www.cookmedical.com
case report
Successful
of
Zilver 635 Biliary
Self-Expanding Stents
Terruzzi Vittorio, M.D. and
Radaelli Franco, M.D.
Ospedale Valduce di Como, Italy
A 70-year-old patient with a six month history of cholangiocarcinoma with hilar
involvement (Klatskin tumor class IIIb, according to Bismuth classification) was
admitted to our department for acute cholangitis. The patient had previously
been treated with chemotherapy and radiotherapy for breast cancer in
2005; past medical history was otherwise unremarkable.
Six months before, the patient came to our attention for jaundice and
fever. A diagnosis of Klatskin tumor was made by imaging (helical CT
and NMR). ERCP was subsequently performed for brushing (which
confirmed the diagnosis of cholangiocarcinoma) and biliary stenting.
After biliary sphincterotomy, 8.5 FR, 12 cm plastic stent (Cotton-
Huibregtse, Cook) and 10 FR, 9 cm plastic stent were positioned
(OASIS-Cook) in the left and right branch, respectively, and good
drainage of the biliary tree was achieved. An explorative laparoscopy
was subsequently made to evaluate the possibility of resectability, but
the patient was considered unfit for surgery due to a nodal involvement.
The patient was jaundiced and febrile when admitted the second time. A
blood culture resulted positive for E. Coli and abdominal ultrasound showed
a diffuse dilation of the intrahepatic biliary tree. An ERCP was urgently planned
for changing the previously placed biliary stents and positioning two metal stents
(ZILBS-635-10-8) in the right and left branches. For this purpose, a large channel (4.2
mm) duodenoscope was used.
After removing both the plastic stents, a Tracer Metro® wire guide (METII-35-480) and a Fusion®
LoopTip wire guide (FS-LT-35-480) were placed through a Glo-Tip II® ERCP catheter (GT-2-T-RB) in
the right and left branches, respectively. Over the wire guides, the metal stents were positioned
across the hilar stenosis. The stent catheters were lubricated with silicon spray, and insertion of the
two stents through the scope was very easy. No problem occurred during cannulation of the papilla.
Once the correct position of both stents across the stenosis was confirmed by fluoroscopy, we started
to partially deploy the left stent for about 15-20 mm, and immediately after we did the same with
the right one. Both systems were then fully deployed simultaneously and both delivery systems were
removed at the same time. The distal end of the right stent was seen out from the papilla. Immediately
after stent deployment, dark bile and pus flowed out the papilla and a complete drainage of contrast
medium from the biliary tree was achieved.
The patient was discharged two days after the procedure. At the 30-day follow-up visit, the patient was doing well,
and total bilirubin was 2.3 g/dL.

The Channel
Dr. Parsons and Northwest Community Hospital dazzle attendees in the
Interventional Interventional Endoscopy Endoscopy Course Course For For GI GI Nurses Nurses and and Technicians Technicians
Dr. Willis G. Parsons and Northwest Community Hospital (Arlington Heights, IL) held their annual
Interventional Endoscopy Course at the Flamingo in Las Vegas, Nevada. The recent event, traditionally
well attended, grew even larger this year: Approximately 200 participants representing 22 states
were treated to several days of interesting lectures, working dry labs and the wonders of the Las
Vegas strip at night.
The annual event featured presentations by Dr. Parsons, Center for Advanced Therapeutic Endoscopy,
Director of Gastroenterology Center at Northwest Community Hospital; Dr. Todd Baron, Professor
of Medicine, Division of Gastroenterology & Hepatology at the Mayo Clinic College of Medicine,
Rochester. Also, presenting were Kathy Lamont, RN, BS, MBA, Director of the Gastroenterology
Center at Northwest Community Hospital and Colleen Himan, RN, MSN, APN, Center for Advanced
Therapeutic Endoscopy. Dry-lab participants received very specialized instruction by faculty from
Northwest Community GI Center and representatives from Cook Medical, Olympus America, Barrx
Medical and Bracco Diagnostics.
On the first day, following early registration, there was a “welcome” reception in which everyone had
time to mingle and become acquainted. This was especially great since participants came from all
over the country and enjoyed sharing stories and making new friendships.
The opening lecture featured Colleen Himan, RN, MSN, APN, addressing “Anatomy and Physiology
of the Biliary/Pancreatic Systems.” She included clinical scenarios along with slides that showed
various anatomical models and terminology that assisted everyone from the experienced nurse and
technician to those just beginning to perform ERCPs. Dr. Parsons consistently engaged the crowd
with his lecture on “ERCP: Biliary Tract Disease” by showing biliary access; biliary sphincterotomy;
stone and stricture management; and how to avoid, recognize and manage complications. During
his lecture the exuberant crowd received various prizes for correctly answering questions regarding
materials covered during the presentation. Afterwards, Dr. Baron’s presentation on “ERCP: Pancreatic
Disease” described various types of pancreatic interventions, while defining fluid collections and
just how and when to intervene. We looked at pancreatitis, pseudocysts and ductal abnormalities
followed by audience questions.
The morning session concluded with interactive dry labs in which participants were able to view and
work with various types of products in a skills-building environment. The group broke out into four
stations that rotated through wire guides (exchanges, biliary access), sphincterotomy, mechanical
lithotripsy (stone management) and stenting. These stations gave key insight into the techniques,
preparation and the do’s and don’ts of ERCP product assistance.
The afternoon session began with Dr. Baron discussing “Enteral Stenting.” He defined indications for
enteral self-expanding stents and described products currently available on the market. He then
demonstrated cases of esophageal, duodenal and colonic SEMS, which lead to group discussion
and questions. Dr. Parsons followed with “Ablation Therapy of Barrett’s Esophagus.” This presentation
discussed disease progression, treatment goals and most common treatment options and concluded
with ablation techniques. Once again the audience was treated to the much-anticipated question
and answer period where participants gained rewards for correct responses. Day One concluded
with Kathy Lamont’s presentation, “Building an Interventional GI Team.” Everyone learned what an
interventional team actually is plus the benefits and the potential downfalls of a select team and
how to avoid them. The training, skill sets, stats and potential Med-Surgical cost per case were also
discussed followed by questions.
Sunday began with a nice breakfast gathering leading into exciting lectures covering EUS/EMR, a
GI bleeding update and a challenging and fun ERCP Flouro Quiz, all given by a very humorous Dr.
Parsons. There was additional time spent in the dry lab with vendors and nurses, covering various
products and procedural techniques. This was the conclusion of a well spent weekend and everyone
left the “City that never sleeps” with a great deal of knowledge and anticipation of returning next
year for this annual program, which will be held at Caesar's Palace in Las Vegas, February 26-28, 2010.
Willis G. Parsons, MD
Director of Gastroenterology
Center for Advanced
Therapeutic Endoscopy
Northwest Community
Hospital
Arlington Heights, IL
Back row (L to R) - Isidro Buenrrostro, GI
Tech; Colleen Shanahan, RN; Kim Scalzitti,
RN; Geraldine De La O, Tech; Alla Pol, Tech;
Laura Mich, RN and Jennifer McLenna, RN.
Front row (L to R) - Diane VanOverbake, RN;
Danilo Samson, GI Tech and Allison
Thielmann, RN
www.cookmedical.com
13

N E X T G E N E R A T I O N
14 www.cookmedical.com
featuring a
design on FS-OMNI and FS-OMNI-35
Cook Endoscopy’s Fusion ERCP product line is advancing ERCP through ongoing product
development with the goal of helping to achieve successful patient outcomes. The next
generation Fusion OMNI features the latest in evolutionary clear catheter technology,
while maintaining the important benefits of our initial sphincterotome design.
From a clinician’s perspective, you now have optimal wire guide visibility throughout
the entire length of the device. As an added benefit, there is a significant reduction in
the amount of force required to initially break through our solid channel design, as
well as having the ability to perform a more efficient exchange by pulling the device
at any angle.
Other notable key features of the Fusion OMNI include the new
look of access with the smooth, round shape of our exclusive
DomeTip design. The Fusion OMNI is the only device on the
market that maintains the choice of your clinical preference as
to whether you choose physician wire guide control or use the
Fusion OMNI in a traditional long wire manner by utilizing our
fully-functional traditional wire guide lumen. Also, if you prefer
to use smaller wire guide diameters, the Fusion OMNI has the
capability of using any wire guide diameter ranging from 035”
to .018” – including the one-of-a-kind Fusion LoopTip – without
having to switch to another device.
The Fusion OMNI streamlines the ERCP process, meeting all of
your clinical needs with one device.
Cook’s Endoscopy Fusion ERCP product line – advancing ERCP
and delivering solutions for successful patient outcomes.

Dr. Peter V. Draganov
Course leader
Dr. Peter V. Draganov
Associate Professor
University of Florida
College of Medicine
Gainesville, FL
Course participants
Dr. M. Rodwan Hiba, MD
Spring Hill Regional Hospital
Brooksville Regional Hospital
Brooksville, FL
Dr. Yasser Saloum, MD
Tampa General Hospital
University of South Florida Surgery
and Endoscopy Center
Tampa, FL
Dr. Ahmed Shobassy, MD
Halifax Medical Center
Advanced Gastroenterology
Center
Port Orange, FL
Course learning objectives
Upon conclusion of this program,
participants should be able to:
• Identify the unique features of
dedicated echoendoscopes and
catheter probes.
• Identify normal EUS anatomy.
• Establish the T, N and M stage
for luminal tumors and
pancreatic cancer.
• Differentiate the various types of
cystic pancreatic tumors.
• Identify the utility of EUS for
evaluating patients with chronic
pancreatitis.
• Differentiate the various
subepithelial mass lesions.
Leads
EUS Course
at the University of Florida
A recent EUS course at the University of Florida
allowed participating gastroenterologists to
gain knowledge and hands-on experience in
a comprehensive multidisciplinary review of
endoscopic ultrasound. The course leader, nationally
renowned expert Dr. Peter Draganov, discussed the
impact and role of EUS in the participants’ practices.
The EUS devices used to instruct the participants
included Cook’s EchoTip® Ultra and Quick-Core®
ultrasound needles as well as the EchoBrush
sampling brush.
Draganov supervised live case demonstrations,
using the opportunity to encourage lively exchanges
between he and the course participants. He
emphasized technical aspects of performing EUS
and demonstrated the use of standard equipment
as well new devices. During each of the cases, he
instructed the clinicians on navigating difficult
anatomy and identifying important anatomical
landmarks. Each case was discussed and clinical
recommendations made before, during and after
the procedures.
The “in-the-room” instruction enhanced the overall
educational experience. At the end of the day, all the
participating clinician were very pleased and came
away with a greater knowledge of EUS products and
better prepared to accurately diagnose and treat
their EUS patients.
The Channel
NEW
The
cutting edge of
optimal sampling
Captura® Disposable Biopsy
Forceps now available in serrated
edged cups.
Cook Medical’s Captura Forceps – now
available with serrated cups – has been
specifically designed to help you acquire
the best possible tissue sample. And,
because the jaws remain closed without
constant handle pressure, you can be
confident that acquired tissue remains
in the cups when extracting the sample.
For controlled passage through the
endoscope, the coated sheath delivers
variable suppleness and rigidity. Cook
forceps: Get on the cutting edge.
COLD
Shaft
Order Number Description Length
DBF-2.4S-230 2.4mm Serrated 230cm
DBF-2.4S-230SP 2.4mm Serrated
with Spike
230cm
DBF-2.4S-160 2.4mm Serrated 160cm
DBF-2.4S-160SP
HOT
2.4mm Serrated
with Spike
160cm
Shaft
Order Number Description Length
HDBF-2.4S-230 2.4mm Serrated 230cm
www.cookmedical.com
15

16 www.cookmedical.com
Cook Medical
Endoscopy
division
President
Bill Gibbons
presents award
to Sun-Young
Lee, MD,
Daniel Von
Renteln, MD and
Andres Sanchez
Yague, MD.
HONORS IMPORTANT CONTRIBUTORS TO ENDOSCOPY
The American Society for Gastrointestinal Endoscopy (ASGE) honored important contributions to
the field of endoscopy during the fifth annual ASGE Crystal Awards on May 31 as part of Digestive
Disease Week (DDW). The always popular and elegant awards banquet was hosted by ASGE and
the ASGE Foundation at the historic Navy Pier on the Chicago lakefront. During the gala, the newly
established Marsha Dreyer Award, sponsored by Cook Medical, was introduced by Cook Medical
Endoscopy division President Bill Gibbons. (See page 8)
Highlighting achievement and dedication, the ASGE Crystal Awards symbolize the finest in leadership,
research and scientific pursuit. The event recognized the 2009 award and grant recipients who have
shared their expertise to advance and strengthen the field of gastrointestinal endoscopy and the
ASGE. Newly designated ASGE Fellows were recognized at this event. Proceeds from the event will
benefit the ASGE Foundation in support of GI endoscopy-related research, physician education and
training, and public outreach initiatives.
The Crystal Awards Dinner featured live music, dinner and presentations to honorees by ASGE
President, John L. Petrini, MD, FASGE, ASGE Foundation Chair, Francis Tedesco, MD, FASGE, various
ASGE leaders and Master of Ceremonies, ASGE Past President and Foundation Trustee, David Carr-
Locke, MD, FASGE.
Crystal Awards recipients include:
Christopher J. Gostout, MD, FASGE, Mayo Clinic, Rochester, MN, winner of the Rudolf V. Schindler
Award, which is ASGE’s highest honor. This award is given to a member whose accomplishments in
endoscopic research, teaching and/or service to ASGE exemplifies the standards and traditions of
Rudolf V. Schindler, MD, founder of the American Gastroscopic Club, the forerunner of ASGE.
George Triadafilopoulos, MD, DSc, FASGE, Stanford University School of Medicine, Stanford, CA,
winner of the Distinguished Service Award, which is granted to an individual who has made long-term
contributions to GI endoscopy in the areas of equipment research and development, as well as an
individual who has been a strong supporter of the educational and research mission of the society.
Anthony N. Kalloo, MD, FASGE, Johns Hopkins Hospital, Baltimore, MD, winner of the Distinguished
Educator Award, which recognizes physicians who substantially contribute to the education of
fellows through endoscopy seminars, participation in national postgraduate courses and published
scholarly reviews or educational materials, including videos.
D. Nageshwar Reddy, MD, Asian Institute of Gastroenterology, Hyderabad, India, winner of the Master
Endoscopist Award, which recognizes physicians who spend the majority of their time in patient
care and are recognized regionally or nationally for their expertise and longitudinal contributions
to the practice of gastrointestinal endoscopy.
Ma Somsouk, MD, MAS, University of California, San Francisco, CA, winner of the Cook Medical
Career Development Award for the project: Defective adaptive immune response and colorectal
neoplasia in HIV infected individuals.
Sun-Young Lee, MD, Konkuk University School of Medicine, Seoul, Republic of Korea, Daniel Von
Renteln, MD, Klinikum Ludwigsburg, Ludwigsburg, Germany, and Andres Sanchez Yague, MD,
Hospital Costa del Sol, Marbella, Spain, each won a Cook Medical Don Wilson Award, which provides
advanced fellows or junior faculty with the opportunity to train outside of their home country
with a premier GI endoscopist or group to advance their training. The awards are named to honor
Don Wilson, founder of Wilson Cook Medical, who was a strong advocate and supporter of
international education and training in GI endoscopy. The awards are underwritten by a grant from
Cook Medical.
Cook Medical congratulates all the 2009 Crystal Award winners. For a complete listing of the winners,
contact ASGE at info@asge.org. The next Crystal Awards Dinner will take place during DDW in May
2010 in New Orleans.

Memory
serves us well
in China
A CASE REPORT
Since our ERCP practice started in 1984, we have gradually built
up an accumulation of experience and understanding along with
a consistent increase in annual procedure numbers. At the same
time, we feel strongly that procedural success rates and safety have
a close correlation with the enhancement of design and quality of
endoscopes as well as accessories. The Memory Basket, 7 FR Hard
Wire (MWB), produced by Cook Medical, is one of our favorites
among a range of extraction device options.
While the CBD stone is a major indication of ERCP, extraction of
stones plays an ultimate and essential role during the procedure
after a sphincterotomy. Common extraction baskets usually handle
well the removal of a single or a few small stones. However, most of
our patients in China often show the presence of common bile duct
dilation with a filling defect and piling of numerous stones or biliary
sludge. Moreover, some patients even have a mass of intrahepatic
stones. In such cases, it is usually difficult for a common basket to
expand and pass across the stones. Instead, the extended basket
can become distorted or bent and fail to capture the stones. For
instance, the wire of one competitive basket may be too floppy
to fully expand, while that of a second competitor’s basket is too
rigid, with a sharp tip that is likely to injure the bile duct. By using
the Memory Basket with spiral wires, we can rotate the handle to
drive the distal end spirally forward. In addition, it is observed that
sometimes the basket goes across the stones even more easily if
we extend only 1/2 or 1/3 of the basket out of the sheath. Thanks
to its wire, which has sufficient strength and good shape retention,
the basket has an extra forward force and extraordinary expansion
The First People’s
Hospital of
Hangzhou, Zhejiang
- One of the most
important ERCP
training centers in
China, completing
over 1,500 ERCP
cases annually.
The Channel
Prof. Zhang Xiao
Director of Endoscopy
Digestive Department of the
First People’s Hospital of Hangzhou, Zhejiang
www.cookmedical.com
17

Figure 1
T-tube cholangiography reveals
image characteristics as a convex
cup edge in lower part of CBD, and
contrast medium fails to flow into
enteric cavity.
Figure 2
After dislodging the stone, the
papilla was dilated and the stone
was successfully extracted.
18 www.cookmedical.com
capability to easily trap stones with less likelihood
of injury to the dissected papilla and inner wall
of the bile duct when extended. The distal end
of the basket has a short, straight and rigid
segment, which together with adjustments
in endoscope orientation, aids in selectively
entering bilateral intrahepatic bile ducts as
needed. The Memory Basket dimensions are
3×6 cm and 2×4 cm, with the former being more
frequently used in our experience.
Case Report
A 75-year-old patient underwent surgery in May 2009
at a local hospital due to acute obstructive suppurative
cholangitis (AOSC). Choledochotomy was performed to
remove stones and a T-tube was deployed for drainage. Prior
to post-operative extubation, routine T-tube cholangiography
was performed and revealed incarceration of a residual stone with a
diameter of about 1 cm in the lower part of common bile duct, showing
image characteristics as a convex cup edge. Contrast medium failed to flow into
the enteric cavity. After two failed attempts of stone removal by choledochoscope, the
patient was referred to our hospital. Repeated T-tube cholangiography demonstrated the
same signs as before. (See Fig. 1)
Routine ERCP was performed with a successful standard cannulation. However, repeated
pushing forward of the wire guide against the stone resulted in the tip of the wire guide
returning to the papillary opening. After sphincterotomy, we tried again to dislodge the
stone by using an ERCP catheter with a preloaded wire guide, but again failed to push the
stone up the duct. Though one of the competitive baskets has a rigid outer sheath with
good pushability, its sharp tip makes us reluctant to use it when considering the risk of bile
duct perforation. Initially, we used a second competitor’s basket, first holding it out against
the stone, and then extending the basket out of the sheath. However, the basket wires bent
back without dislodging the stone. After we changed to a Memory Basket (MWB-3x6), the
stone was successfully pushed upward to the middle segment of the dilated common bile
duct when we extended the basket wires abruptly. After dilation of the papillary opening to
one cm, the stone was successfully extracted by the basket. (See Fig. 2)
This case features a post-operative residual stone with incarceration. Two following attempts
at stone removal by choledochoscope might have pushed the stone to a narrow lower
segment of the CBD, resulting in an even tighter incarceration and more difficulties in lifting
and freeing the stone during subsequent ERCP. An initial attempt at stone dislodgement with
a competitor’s basket was unsuccessful, with the basket simply bending back when being
extended against the stone. This may have been due to the baskets thin wire multifilament
composition and the low pushability of its soft sheath. However, benefiting from the great
catheter pushability and atraumatic blunt tip design of the Memory Basket, we eventually
succeeded in extracting the stone. During the essential attempt of pushing the stone up
the duct, the monofilament spiral wire was able to drive the incarcerated stone ahead once
it had loosened slightly.

The Channel
N E W S F R O M
SIGNEA
Society of International Gastroenterological Nurses and Endoscopy Associates
Dr. Fazel is the Chief of Gastroenterology and Medical Director for Advanced Endoscopy at INOVA Fairfax Hospital in Fairfax, Virginia.
According to the American Cancer Society
(ACS), more than 16,000 new esophageal
cancer cases are diagnosed each year in
the U.S. Unfortunately the survival rate in
these cases is only 10 percent. This alarming
statistic is due largely to the fact that by the
time the majority of cases are diagnosed, the
cancerous tumors have grown to the point of
inoperability. Raising patient awareness about
potential conditions that, if left untreated, could
progress into esophageal cancer, will encourage
patients to seek the appropriate care through
their physician.
Contributing Risk Factors
Many people are aware that tobacco use
increases the risk of developing esophageal
cancer; however, there are several other
common contributing risk factors including:
excessive alcohol consumption, obesity, lye
ingestion and gastroesophageal reflux disease
(GERD), also known as acid reflux or heartburn.
A recent ACS Gallup poll revealed that 44
percent of adults in the U.S. have heartburn at
least once per month and that approximately
30 percent of esophageal cancer cases can be
linked to GERD. GERD is a condition in which
acid (with some pepsin and bile) splashes up
from the stomach into the esophagus. These
three fluids are potentially dangerous to the
sensitive esophageal tissue, as they can damage
the lining of the esophagus, a condition known
as esophagitis.
If GERD becomes a chronic condition, it can
develop into Barrett’s esophagus, a precursor
to esophageal cancer. Barrett’s esophagus is a
condition in which the color and composition
of the cells lining the lower esophagus change
due to repeated exposure to stomach acid. Only
a small percentage of people with GERD develop
Barrett’s esophagus, but once it is diagnosed,
patients should be sure to meet with their
physician regularly as they are at a greater risk
of developing esophageal cancer.
Symptoms of advanced GERD or the presence
of Barrett’s esophagus include:
Frequent heartburn. A burning-type
pain in the lower part of the mid-chest,
behind the breast bone, and in the
mid-abdomen.
Difficulty swallowing. Often, a narrowing
of the esophagus (esophageal stricture)
leads to trouble swallowing or dysphagia.
Bleeding. A person may vomit red blood
or blood that looks like coffee grounds, or
your stools may be black, tarry or bloody.
Weight loss and loss of appetite.
According to the ACS, prevention of Barrett’s
esophagus can begin with controlling GERD by
making some simple lifestyle changes, such as:
Losing weight. Obesity increases
abdominal pressure, which can then push
stomach contents up into the esophagus;
Eating a diet full of fruits and vegetables,
eating smaller and more frequent meals
and not eating two to three hours prior
to bedtime;
Smoking cessation, as nicotine relaxes
the esophageal sphincter and smoking
also stimulates the production of
stomach acid;
Discontinuing the consumption
of alcohol.
People with severe GERD and Barrett’s
esophagus often require aggressive treatment
and prevention methods including medications,
other nonsurgical medical procedures such as
endoscopic therapies, or even laparoscopic
and open surgeries. Often times, swallowing
difficulty (known as dysphagia) and other
symptoms can be treated if identified early.
Technologies Emerging
However, due to the aggressive nature of
the disease, the majority of patients who
have esophageal cancer are not surgical
candidates. In these situations, the primary focus
becomes palliative care – providing comfort
measures to help maintain quality of life. This
includes treating the dysphagia and restoring
the patient’s ability to swallow food and
drink liquids by opening the stricture within
the esophagus.
To open the barriers caused by tumor in-growth
physicians use an esophageal metal stent. Prior
to the stent placement the patient may require
dilation of the stricture to allow room for the
stent to be positioned, thereby expanding
the lumen of the esophagus. Traditionally,
the placement of the stent can be a painful
process for the patient, yet new technologies
are making this procedure easier on the patient
and physician.
New, innovative delivery systems enable
accurate deployment and recapturability of the
stent. This reduces the stent from moving or
migrating into the stomach and thus the need
for repeat procedures to replace or reposition the
stent, one of the more common complications
in traditional esophageal stenting.
Increase Awareness
Raising awareness about the primary precursors
to esophageal cancer – GERD and
Barrett’s esophagus – will encourage patients
with these conditions to consult their physicians
for the necessary screenings and treatment
options. However, when palliative care becomes
the primary option for patients with esophageal
cancer, recent advancements in medical device
technologies enable physicians to more easily
implant an esophageal stent and in turn
improve patients’ quality of life.
www.cookmedical.com
19

Cook Medical has long understood that optimal
patient care is your focus, and it continues to be
our focus as well. That’s why for more than twenty
years we have assisted healthcare professionals
in learning the latest in endoscopic GI technology
and related disease information.
That tradition continues as Cook Medical, in
partnership with HealthStream (an accredited
provider of continuing nursing education), offers
three new educational activities:
Updates in Esophageal Cancer with
Focus on Barrett’s Esophagus
Updates in Esophageal Cancer with
Focus on Therapeutic Treatment Options
Updates in Esophageal Cancer with
Focus on Diagnosis and Palliation
We are pleased to announce that the American Board
of Certification for Gastroenterology Nurses (ABCGN)
has reviewed these educational activities and
recognized them as providing GI specific content.
These activities are presented without charge by
your Cook Medical district manager. Educational
activity descriptions, objectives and the related
accreditation information can be found at http://
www.cookendoscopy.com/educationalpages/
edprograms.html.
Contact your Cook representative for more
information or to arrange a presentation
opportunity.
A continuing nursing education activity sponsored by
HealthStream. Grant funds provided by Cook Medical.
20 www.cookmedical.com
UPCOMING EVENTS
ACG Regional Post Graduate Kansas City, MO Aug. 28-29
Mayo Clinic - ERCP A-Z Rochester, MN Sept. 17-18
ASGE - Excellence in GI Endoscopy Nursing Oak Brook, IL Sept. 25
Asian Pacific Digestive Week (APDW) 2009 Taipei, Taiwan Sept. 28-Oct. 1
Int. Course on Therapeutic Endoscopy (Marcon) Toronto, Canada Sept. 30-Oct. 3
CSGNA (Canadian Society Of
Gastroenterological Nurses)
Toronto, Canada Oct.1- 3
Gastroenterology & Hepatology (UCI) Las Vegas, NV Oct. 2-4
Boston Live Endoscopy Boston, MA Oct. 8-9
JDDW Kyoto, Japan Oct. 14-17
AGW Brisbane, Australia Oct. 22-26
ACG (American College of Gastroenterology) San Diego, CA Oct. 25-28
Interventional GI Endoscopy Techniques Strasbourg, France Oct. 26-28
MUSC - ERCP for Physicians Charleston, SC Oct. 29-30
AASLD (Liver Meeting) Boston, MA Oct. 30 - Nov. 3
Harvard Live EUS 09 Boston, MA Nov. 6-8
UEGW & WCOG Congress London, UK Nov. 21-25
ASGE - ERCP Boot Camp for the GI Team Oak Brook, IL Dec. 4-5
MUSC - EUS for Physicians Charleston, SC Dec. 4-5
24th International Workshop
on Therapeutic Endoscopy
Hong Kong Dec. 8 - 10
MUSC - EUS for Nurses Charleston, SC Dec. 10-11
NYSGE New York, NY Dec. 16-19
An official publication of Cook Medical.
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