D P Hurlstone

Sheffield Hallam University, Sheffield, England, United Kingdom

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Publications (119)663.5 Total impact

  • D P Hurlstone, R Kiesslich, M Thomson
    Gut 12/2008; 57(11):1634. · 10.73 Impact Factor
  • David A Elphick, David P Hurlstone
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    ABSTRACT: Endoscopic submucosal dissection (ESD) is a revolutionary procedure that allows for en bloc resection of large tumors in the gastrointestinal tract; however, complications can occur including perforation and bleeding. In this Practice Point commentary, we discuss the findings and limitations of a retrospective study conducted by Takizawa and colleagues that investigated risk factors for delayed bleeding in patients with gastric cancer who underwent ESD. The findings of their study suggest that preventative electrocoagulation of nonbleeding visible vessels after ESD might reduce the incidence of delayed bleeding. In addition, tumor location was found to influence the rate of delayed bleeding. This commentary highlights the issues to consider when interpreting these findings in clinical practice, and we consider the resonance of these results for ESD of colorectal tumors.
    Nature Clinical Practice Gastroenterology &#38 Hepatology 09/2008; 5(10):544-5. · 5.33 Impact Factor
  • David P Hurlstone
    Gastroenterology 08/2008; 135(2):338-43. · 12.82 Impact Factor
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    ABSTRACT: Advances in imaging technology and engineering have now permitted functional integration of a confocal endomicroscope into the distal tip of a conventional video colonoscope enabling imaging of the surface epithelium and the underlying lamina propria during ongoing video endoscopy. For the first time, the endoscopist is now able to resolve the surface and subsurface mucosa at cellular resolution in vivo and in real time. A new era in endoscopic imaging has therefore begun - histoendoscopy. In addition to providing a high-accuracy in vivo optical biopsy tool for the differentiation between benign hyperplasia, intra-epithelial neoplasia and carcinoma in sporadic cohorts, endomicroscopy with targeted biopsies has now been shown to increase the yield of intra-epithelial neoplasia complicating ulcerative colitis. Furthermore, recent data examining endomicroscopic molecular ex vivo imaging using anti-CD44v6 antibody has identified aberrant crypt foci based on their surface molecular expression. Receptor overexpression in vivo in humans may, in the near future, be exploited for the diagnosis of inflammation, neoplasia and in predicting targeted molecular therapy. Endomicroscopy will be key to this immuno-imaging interface. Within the present review, we discuss the current clinical evidence in support of confocal endomicroscopy and explore the new diagnostic possibilities for this technology.
    Journal of Gastroenterology and Hepatology 07/2008; 23(7 Pt 1):1009-23. · 3.33 Impact Factor
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    ABSTRACT: This article has been withdrawn consistent with Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). The Publisher apologizes for any inconvenience this may cause.
    Gastroenterology 06/2008; · 12.82 Impact Factor
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    ABSTRACT: Conventional colonoscopy has a significant false-negative rate for intraepithelial neoplasia. Chromoendoscopy increases sensitivity but lacks specificity. The aim was to assess prospectively the clinical applicability and predictive power of the EC3870CIFK confocal laser endomicroscope (CLE) for the in vivo diagnosis of intraepithelial neoplasia during colonoscopy. Lesions were identified using chromoscopy followed by CLE imaging and graded according to vascular and cellular changes. CLE imaging of circumscribed lesions and four segmental 'normal' colorectal quadrants was performed. Targeted biopsy specimens were then compared with histopathological results. Forty patients completed the protocol (22 men and 18 women; median age 62 (range 39-82) years). The median duration of ileal intubation and total procedure time were 12 (range 5-26) and 55 (range 28-92) min respectively. Chromoscopic colonoscopy revealed 162 lesions in 39 patients. CLE imaging was obtained on all 162 lesions. Some 5422 confocal images were compared with 802 targeted biopsy specimens. Intraepithelial neoplasia was predicted with an accuracy of 99.1 per cent (sensitivity 97.4 per cent and specificity 99.3 per cent) (P = 0.711). Confocal laser endomicroscopy permits high-quality cellular, subsurface vascular and stromal imaging, enabling prediction of intraepithelial neoplasia with a high level of accuracy.
    British Journal of Surgery 06/2008; 95(5):636-45. · 4.84 Impact Factor
  • Gastrointestinal Endoscopy 06/2008; 67(6):1000-4. · 5.21 Impact Factor
  • D P Hurlstone, B P Saunders, J M Church
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    ABSTRACT: Persistence of underlying disease in the residual rectal mucosa and anal transition zone occurs following mucosectomy with either a hand-sewn anastomosis or a double-stapled anastomosis. Furthermore, recent reports have suggested an increased incidence of neoplasia in the pouch body. For this reason, endoscopic surveillance is performed not only as a screening tool to detect significant intraepithelial neoplastic lesions but also with secondary therapeutic intent aimed at reducing the adenoma burden within the ileoanal pouch. Conventional endoscopic assessment of the ileoanal pouch can be challenging. In the future, novel adjunctive endoscopic technologies such as magnification endoscopy and confocal endomicroscopy may improve our diagnostic and therapeutic management of this group.
    Endoscopy 06/2008; 40(5):437-42. · 5.74 Impact Factor
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    ABSTRACT: Resection of an adenoma-like mass (ALM) in chronic ulcerative colitis (CUC) complicated by mucosal fibrosis has historically not been technically feasible. Endoscopic submucosal dissection techniques may now provide a therapeutic tool enabling the division of submucosal fibrotic scarring, hence enabling endoluminal resection for the first time in this select patient group. The aim was prospective evaluation of endoscopic submucosal dissection-assisted (ESD) resection of flat, sessile, and lateral spreading tumors in CUC complicated by submucosal desmoplasis. Clinical endpoints were postresection recurrence rates, R0 resection status, and complications. ESD-assisted endoscopic mucosal resection (EMR) using the Olympus KD-630L insulation-tipped knife was performed on selected lesions. Sixty-nine patients met inclusion criteria, of which 2 were excluded due to follow-up default. En bloc resection was performed in 52/67 (78%) cases with 15/67 (7%) requiring a piecemeal approach. R0 resection was achieved in 49/52 (94%) of lesions undergoing en bloc resection (perforation rate 2/67 [3%]). Bleeding complications occurred in 7/67 (10%) of cases. No metachronous circumscribed intraepithelial neoplastic lesions or cancer was detected at follow-up. At a median of 18 months follow-up, overall cure rates for the ESD-assisted EMR cohort was 66/67 (98%). We have shown for the first time that endoscopic resection of ALM even in the presence of complicating mucosal fibrosis is technically achievable using a combined ESD-assisted EMR technique. In an appropriately selected cohort, this technique may provide a technically feasible and clinically acceptable therapy where otherwise colectomy would be required.
    Inflammatory Bowel Diseases 06/2008; 14(10):1380-6. · 5.12 Impact Factor
  • W Baraza, F Lee, S Brown, D P Hurlstone
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    ABSTRACT: Self-expanding metallic stents have found increasing use in the palliation of malignant large-bowel obstruction or as a 'bridge to surgery' to facilitate a planned operative procedure. We describe a 5-year experience of using the combined endoscopic/fluoroscopic through-the-scope method of stent placement in a tertiary referral centre. A prospective database of patients referred for colorectal stenting was compiled. Technical success, clinical success (decompression) and procedure-related complications were measured as end-points. Sixty-three patients underwent 71 stenting procedures; 39 (62%) patients were male and the median age of patients was 78 years; 32 patients had metastatic disease and seven strictures were due to extrinsic compression. The indication for stenting was palliation in 56 patients and preoperative in seven patients. There was a technical success rate of 91% and a clinical success rate of 89%. Complications occurred in 24% of the cohort: overgrowth, (8%), migration (6%), fistulation (4%), stent fracture (3%), tenesmus (3%) and faecal urgency (1%). There was no procedure-related death within the cohort and no technical failures proximal to the descending colon. Combination endoscopic/fluoroscopic colorectal stenting is effective and safe. It may be particularly useful in the stenting of more proximal colonic strictures.
    Colorectal Disease 05/2008; 10(9):901-6. · 2.08 Impact Factor
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    ABSTRACT: The implementation of bowel cancer screening in the UK requires the maintenance of high standards in colonoscopy. Part of this quality control requires the reliable documentation of complete colonoscopy that can be externally audited and assessed. It has been suggested that terminal ileal biopsy is the only definitive and reliable method of confirming caecal intubation, but it is not cost-effective and may now be contraindicated because of potential prion infection. To determine how reliable routine terminal ileal images were as an independent predictor of complete colonoscopy and whether their interpretation was aided with water insufflation or indigo-carmine dye-spraying. Method Forty-nine histologically confirmed terminal ileal images were obtained from a single endoscopist's database; 19 were conventional white-light images, 15 were taken with water insufflation and 15 were taken using chromoscopy enhancement. The images were transferred onto CD-ROM and sent as a questionnaire to 42 colonoscopists who were asked to identify the images as terminal ileum or not. Twenty questionnaires were returned resulting in a total of 980 responses. Overall, the accuracy of positive identification was 53.4%. Water insufflation and chromoscopy improved the accuracy to 68.3% and 63% respectively. Experience of (> 1000 colonoscopies) did not increase overall accuracy. Less experienced endoscopists had an increased accuracy rate with dye-spraying (76.7%vs 59.3%, P < 0.05) but experienced endoscopists had an increased accuracy rate with water insufflation (67.4%vs 63.3%, P > .05). Currently, terminal ileal imaging is not a reliable mode of documenting complete colonoscopy. Using water insufflation or dye-spraying coupled with modifications in image acquisition technique may improve its reliability but these methods require further investigation before they can replace the use of caecal landmarks as completion parameters.
    Colorectal Disease 04/2008; 11(1):89-93. · 2.08 Impact Factor
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    ABSTRACT: Recently, miniaturization of a novel confocal laser endomicroscope (Optiscan Pty, Notting Hill, Victoria, Australia) has permitted functional integration into the distal tip of a conventional video colonoscope (Pentax EC3870K; Pentax, Tokyo, Japan) enabling imaging of the surface epithelium and the underlying lamina propria during ongoing video endoscopy. Using endomicroscopy and intravenous sodium fluorescein as a contrast agent, 'virtual histology' can be created, which allows visualization of both the surface epithelium, and some of the lamina propria (down to a quarter of a millimetre), including the microvasculature. Confocal endomicroscopy may have major implications in the future of colonoscopy as uniquely it allows in vivo diagnosis of colonic intraepithelial neoplasia and carcinoma enabling 'smart' biopsy targeting and hence potentially influencing 'on table' management decisions. Initial pilot data have now shown that confocal imaging in vivo using the newly developed EC3870K has high overall accuracy for the immediate diagnosis of intraepithelial neoplasia and carcinoma in sporadic screened cohorts, but also has a role in the detection of intraepithelial neoplasia detection in chronic ulcerative colitis cancer screening when used in conjunction with methylene blue chromoscopy. We discuss the current evidence in support of confocal endomicroscopy in the colorectum and explore the new diagnostic possibilities for this technology.
    Histopathology 04/2008; 52(4):417-26. · 2.86 Impact Factor
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    ABSTRACT: The optimal serologic tests for the detection of celiac disease and follow-up assessment remains controversial. Our aim was to evaluate all current immunologic assays for diagnosing celiac disease using the gold standard of duodenal biopsy. We also assessed whether tissue transglutaminase (tTG) antibody is a quantitative marker for histologic severity. Consecutive adult patients referred for gastroscopy without a previous known diagnosis of celiac disease were recruited (group 1). Concurrently, patients with a known diagnosis of celiac disease on a gluten-free diet for more than 1 year undergoing repeat duodenal biopsy were identified (group 2). All patients had duodenal biopsies and serologic analysis performed for immunoglobulin(Ig) A and antibodies to human immunoglobulin (Ig)A-tTG, IgA-gliadin, IgG-gliadin, and IgA-endomysial antibody. Two thousand patients were recruited in the first group. Seventy-seven (3.9%) patients were diagnosed with new celiac disease. The sensitivity, specificity, positive predictive value, and negative predictive value for IgA tTG were 90.9%, 90.9%, 28.6%, and 99.6%. When adopting a 2-step approach using tTG first and then EMA the sensitivity, specificity, positive predictive value, and negative predictive value was 85.7%, 98.6%, 71.7%, and 99.7%, respectively. The use of nondeamidated IgA/IgG gliadin antibodies conferred no additional diagnostic benefit when considering the detection of adult celiac disease. In the second group 48 patients with celiac disease on a gluten-free diet were identified. Sixteen of 48 of these patients had persisting villous atrophy, but 7 of 16 (44%) had a normal tTG level. IgA tTG alone is a sensitive marker for celiac disease. A normal tTG level does not predict recovery of villous atrophy in patients with celiac disease on a gluten-free diet.
    Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 04/2008; 6(3):314-20. · 5.64 Impact Factor
  • Gastroenterology 04/2008; 134(4). · 12.82 Impact Factor
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    ABSTRACT: A prospective technical feasibility study of cap assisted ESD for 'curative intent' in patients with residual or local neoplastic recurrence following EMR. Primary end points were second stage R0 resection rate, safety and recurrence. Salvage ESD was performed using the Olympus GIF-XQ240 gastroscope and KD-630L insulation tipped knife. Thirty-day mortality, re-admission rates, complications and histological resection status were collected prospectively up to 9 months following index resection. Thirty patients met eligibility criteria. Index R0 resection was achieved in 25/30 (83%) lesions. One patient underwent surgical excision with a second receiving a curative second stage dissection. Ninety-six per cent (29/30) patients were discharged within 24 h of the procedure with a 0% 30-day mortality and re-admission rate. Bleeding occurred in 5/30 (16%) treated successfully with endoluminal haemostasis. There were no perforations. Overall 'cure' rates at short-term follow-up [median 6/12 (range; 3-18)] was 96%. This novel application of ESD for first line 'salvage' therapy in treating residual or locally recurrent neoplastic disease may be a safe, minimally invasive and cost effective alternative to direct surgical resection in a select patient cohort.
    Colorectal Disease 04/2008; 10(9):891-7. · 2.08 Impact Factor
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    Robert James Atkinson, David Paul Hurlstone
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    ABSTRACT: See article in J. Gastroenterol. Hepatol. 2008; 23: 218–221.
    Journal of Gastroenterology and Hepatology 03/2008; 23(2):165-6. · 3.33 Impact Factor
  • Robert James Atkinson, David Paul Hurlstone
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    ABSTRACT: Upper gastrointestinal haemorrhage remains a significant cause of hospital admission, with mortality rates up to 14%. In order to standardise and improve care, various scoring systems (e.g. Rockall, Blatchford and Baylor) have been developed to identify those individuals at high risk of requiring treatment (transfusion, endoscopic or surgical intervention) or of re-bleeding or death. There is also increasing interest in the utilisation of scoring systems to identify individuals at low risk of complications, as these may be discharged early, possibly with outpatient endoscopy. Most scoring systems are developed to predict outcomes in non-variceal bleeding. However, several indices are used to predict the outcome of advanced liver disease, including Child-Pugh and the Model of End-Stage Liver Disease (MELD). This chapter reviews all these aspects of the various scoring systems.
    Baillière&#x027 s Best Practice and Research in Clinical Gastroenterology 02/2008; 22(2):233-42. · 3.16 Impact Factor
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    ABSTRACT: Loss of mucosal 'lift' prior to submucosal dissection or endoscopic mucosal resection (EMR) increases the risk of complications. We conducted a randomized controlled trial comparing dextrose solution with sodium hyaluronic acid (SHA) for the EN BLOC resection of Paris type I/0-II and lateral spreading lesions of the colorectum. Patients with Paris type I/0-II or lateral spreading tumor lesions of < 30 mm were randomized in a 1 : 1 ratio to undergo EMR using either dextrose solution or SHA. The primary study outcome was complete resection. Secondary outcomes were endoscopic complications (i. e. perforation or bleeding) and polyp recurrence rates. A total of 174 patients were randomized. R0 resection was achieved in 59 of the 82 lesions (72 %) in the dextrose group and 56 of the 81 lesions (69 %) in the SHA group ( P > 0.1), with no significant difference in median lesion diameter ( P > 0.1). The median number of post resection surveillance colonoscopies was 3 (range 2 - 7) in the dextrose group and 4 (range 2 - 6) in the SHA group ( P = NS). The median post index EMR resection follow-up period was 20 months (range 4 - 26) in the DS group and 18 months (range 3 - 22) in the SHA group ( P = NS). Recurrence rates were 1/82 (1.21 %) in the dextrose group and 1/81 (1.23 %) in the SHA group ( P = NS). EMR using dextrose solution is as effective as SHA in terms of resection completion, recurrence rates, and complications.
    Endoscopy 02/2008; 40(2):110-4. · 5.74 Impact Factor
  • Wal Baraza, Simon S. Cross, Steven R. Brown, David P. Hurlstone
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    ABSTRACT: In the 40 years since its introduction, colonoscopy has revolutionized the detection of colorectal cancer and its precursors. Recent advances in colonoscopic technique have had an important effect on histopathology, (e.g. type of colorectal specimen derived, new interpretative information produced by endoscopists). The authors are endoscopists who use these new techniques to provide histopathologists with relevant information: the Paris classification of endoscopically visualised lesions, the Kudos classification of pit pattern, the technique of endoscopic mucosal resection, and the management implications of the different classifications.
    Diagnostic Histopathology 02/2008; 14(2):99-109.
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    ABSTRACT: The diagnosis of intraepithelial neoplasia is pivotal for ongoing clinical management decisions in ulcerative colitis. Previous studies have compared the diagnostic yield of endomicroscopy with conventional "white light" endoscopy and hence the overall objective increase of endomicroscopy targeted biopsies as compared to chromoscopy guided alone is not apparent. We performed a prospective randomised controlled study to compare the diagnostic yield of intraepithelial neoplasia and cancer in patients undergoing ulcerative colitis screening using chromoscopy assisted endomicroscopy (group A) versus pan-colonic chromoscopy assisted colonoscopy (group B). Patients were randomised in a 1:1 ratio to undergo screening colonoscopy using either chromoscopic endomicroscopy or chromoscopy alone with targeted biopsies. Circumscribed lesions were characterised using endomicroscopy and chromoscopy with pit pattern analysis. Targeted biopsies in addition to conventional 10 cm quadrantic biopsies were taken. Primary outcome addressed the number of intraepithelial neoplasias detected in each group. Endomicroscopy targeted biopsies significantly increased the yield of intraepithelial neoplasia as compared to pan-chromoscopy and biopsy alone (p<0.001) and also increased the yield of high-grade dysplastic lesions (p<0.001). Endomicroscopy targeted biopsies increased the diagnostic yield of intraepithelial neoplasia as compared to chromoscopy guided biopsies alone by 2.5-fold. This is the first randomised controlled study to show the true clinical benefit of endomicroscopy for the in vivo detection and characterisation of intraepithelial neoplasia in chronic ulcerative colitis surveillance colonoscopy. Endomicroscopy with targeted biopsy may potentially be the "gold standard" for the detection of intraepithelial neoplasia in ulcerative colitis.
    Gut 02/2008; 57(2):196-204. · 10.73 Impact Factor