Letters to the editor

(Fig 1D). There were no adverse events in the procedure, and the patient’s condition improved with cessation of the bleeding. The patient was discharged 4 days later, and there has been no recurrence of bleeding during a follow-up period of 2 weeks. Bleeding during or after drainage of pseudocysts is an uncommon but severe adverse event of both endoscopic and surgical drainage.1 Arterial bleeding from a pseudoaneurysm can be catastrophic, and various hemostatic methods such as placement of metallic stents, angiography and embolization, and hemospray application have been described in the medical literature.1,2 After searching the literature, we believe that endoscopic injection of cyanoacrylate glue directly into the pseudoaneurysm has not been previously described. Surinder Singh Rana, DM Department of Gastroenterology Manphool Singhal, MD Department of Radiodiagnosis Amit Sharma, MD Vishal Sharma, DM Department of Gastroenterology Mukesh Kumar Yadav, MD Department of Radiodiagnosis Rajesh Gupta, MCh Department of Surgery Deepak Kumar Bhasin, DM Department of Gastroenterology Post Graduate Institute of Medical Education and Research Chandigarh, India REFERENCES 1. Saftoiu A, Ciobanu L, Seicean A, et al. Arterial bleeding during EUSguided pseudocyst drainage stopped by placement of a covered selfexpandable metal stent. BMC Gastroenterol 2013;13:93. 2. Tarantino I, Barresi L, Granata A, et al. Hemospray for arterial hemorrhage following endoscopic ultrasound-guided pseudocyst drainage. Endoscopy 2014;0946 Suppl 1)UCTN:E71. http://dx.doi.org/10.1016/j.gie.2014.09.057

Lubiprostone in small-bowel capsule endoscopy: meta-analyzing the data To the Editor: We read with great interest the article by Pérez-Cuadrado Martínez and Pérez-Cuadrado Robles1 on capsule endoscopy and deep enteroscopy. We would like to focus on the reported use of lubiprostone, a selective activator of type 2 chlorine channels in the apical membrane of the GI epithelium, in small-bowel capsule endoscopy. A recent randomized, 3-way crossover study from Japan2 showed that lubiprostone significantly reduces the small-bowel transit time (SBTT) and improves visualization of the mucosa durwww.giejournal.org

Figure 1. A, Pooled effect of Lubiprostone on gastric transit time (GTT) and B, small-bowel transit time (SBTT). SD, standard deviation; CI, confidence interval.

ing small-bowel capsule endoscopy. In 2009, Hooks et al3 studied the effect of lubiprostone in a double-blinded, placebo-controlled trial and found that although lubiprostone increased the gastric transit time (GTT), it did not result in a significant decrease in SBTT compared with placebo. Our group has looked into the usefulness of prokinetics in capsule endoscopy.4 We demonstrated that overall, prokinetics improved the examination completion rate. However, the effect on GTT and SBTT was less clear. Recently, we pooled new data on the use of mastic gum (as a prokinetic) to show that there is no evidence to support the use of chewing gum in small-bowel capsule endoscopy.5 After our previous reports, we thought that it would be useful to meta-analyze the current evidence on lubiprostone (Fig. 1). It becomes evident that lubiprostone reduces GTT, whereas there is no evidence that SBTT is affected. However, owing to the small number of participants, those results should be interpreted with caution.

DISCLOSURE The following author disclosed financial relationships relevant to this publication. A. Koulaouzidis: research grants from Given Imaging Ltd, material support for capsule endoscopy research from SynMed UK, travel support from MSD, Dr FalkPharma, Abbott, and Almirall, Volume 81, No. 4 : 2015 GASTROINTESTINAL ENDOSCOPY 1047

Letters to the editor

and honoraria from Dr FalkPharma UK. All other authors disclosed no financial relationships relevant to this publication. Andry Giannakou, PhD Faculty of Economics and Management Open University of Cyprus Nicosia, Cyprus Konstantinos J. Dabos, MD, PhD Anastasios Koulaouzidis, MD, FRCPE, FACG Centre for Liver and Digestive Disorders The Royal Infirmary of Edinburgh Edinburgh, UK REFERENCES 1. Pérez-Cuadrado Martínez E, Pérez-Cuadrado Robles E. Capsule endoscopy and deep enteroscopy. Gastrointest Endosc 2014;80:396-9. 2. Matsuura M, Iida H, Nonaka T. Lubiprostone decreases small-bowel transit time and improves visualization of the small bowel in capsule endoscopy: a double- blind, placebo-controlled 3-way crossover study. Gastroenterology 2014;146(5 suppl 1):S-358. 3. Hooks SB 3rd, Rutland TJ, Di Palma JA. Lubiprostone neither decreases gastric and small-bowel transit time nor improves visualization of small bowel for capsule endoscopy: a double-blind, placebo-controlled study. Gastrointest Endosc 2009;70:942-6. 4. Koulaouzidis A, Giannakou A, Yung DE, et al. Do prokinetics influence the completion rate in small-bowel capsule endoscopy? A systematic review and meta-analysis. Curr Med Res Opin 2013;29:1171-85. 5. Dabos KJ, Giannakou A, Koulaouzidis A. Chewing gum and completion rate in small-bowel capsule endoscopy: meta-analyzing the data. Gastrointest Endosc 2014;79:1032-4. http://dx.doi.org/10.1016/j.gie.2014.10.001

be needed to clarify conclusively the role of prokinetics such as lubiprostone in CE. Enrique Pérez-Cuadrado Robles, MD Enrique Pérez-Cuadrado Martinez, PhD Small Bowel Unit Department of Gastroenterology Morales Meseguer Hospital Murcia, Spain

REFERENCES 1. Matsuura M, Iida H, Nonaka T. Lubiprostone decreases small-bowel transit time and improves visualization of the small bowel in capsule endoscopy: a double-blind, placebo-controlled 3-way crossover study. Gastroenterology 2014;146(5 suppl 1):S358. 2. Koulaouzidis A, Giannakou A, Yung DE, et al. Do prokinetics influence the completion rate in small-bowel capsule endoscopy? A systematic review and meta-analysis. Curr Med Res Opin 2013;29:1171-85. 3. Pons Beltrán V, González Suárez B, González Asanza C, et al. Evaluation of different bowel preparations for small bowel capsule endoscopy: a prospective, randomized, controlled study. Dig Dis Sci 2011;56:2900-5. http://dx.doi.org/10.1016/j.gie.2014.11.009

Severe radiation esophagitis successfully treated with Ankaferd hemostat To the Editor:

We read the letter by Dr Giannakou et al with great interest and would like to respond to his concerns. There is no consensus regarding purgative agents and prokinetics in capsule endoscopy (CE). Most studies to date have considered mucosal visualization and complete smallbowel transit (SBT), measuring gastric and SB transit times (SBTT) to analyze their impact. However, we would like to stress that the main purpose of these agents is to increase the diagnostic yield of small-bowel disorders. In this sense, it is not clear that the reduced SBTT or optimal mucosa visualization will have a significant impact on the global detection rate of small-bowel lesions by CE.1 The shorter SBBT can lead to the capture of fewer frames and undiagnosed pathologic images. Koulaouzidis et al2 have analyzed the influence of prokinetics on the examination completion rate. By contrast, in a prospective, randomized controlled study3 we have analyzed different preparations with purgative agents, reporting similar results for sodium phosphate, polyethylene glycol electrolyte, and clear liquids. Therefore, we fully agree with the call for caution in interpreting the results of different studies concerning prokinetics to date. Further studies will

Radiation esophagitis is an early and common adverse effect of radiation treatment. Its incidence is greater with higher radiation dose and concurrent chemotherapy. Strictures are the imminent adverse event. Currently, there is no ideal therapy to prevent stricture formation resulting from chemoradiotherapy. We have previously demonstrated the beneficial effect of Ankaferd blood stopper (ABS; Ankaferd Ilaç Kozmetik AS, Istanbul, Turkey), a recently developed hemostatic agent, in the treatment of caustic esophagitis in an experimental model.1 Here we report the first human case of severe radiation esophagitis treated with topical ABS. A 67-year-old woman who had been followed up for breast cancer since 2003 was admitted to our outpatient clinic. She had been given radiotherapy for her cancer that had metastasized to the vertebrae in July 2014. She had experienced dysphagia after the tenth radiotherapy cure and consulted our gastroenterology department. Upper endoscopy demonstrated a circumferentially surrounding ulcer at the lower esophagus (Fig. 1). Topical ABS 10 mL was sprayed onto the ulcer endoscopically as previously described.2 She was advised to drink 10 mL of ABS daily for 10 days. Repeated upper endoscopy showed that the ulcer healed completely after 20 days of ABS treatment. Acute esophagitis is treated symptomatically. Although interruption of radiation therapy is sometimes necessary because of the severe symptoms, this approach may

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Lubiprostone in small-bowel capsule endoscopy: meta-analyzing the data.

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