2019版《中国消化内镜诊疗相关肠道准备指南》解读

随着内镜技术的发展和普及,肠镜检查的重要性进一步突显,肠道准备作为肠镜检查的前提条件显得尤为重要。为进一步改进我国内镜检查前肠道准备的方法,提高内镜检查的质量,结合我国实际情况,中国医师协会内镜医师分会消化内镜专业委员会联合中国抗癌协会肿瘤内镜学专业委员会对旧版指南进行了更新。本文对2019版《中国消化内镜诊疗相关肠道准备指南》的更新内容进行解读,以期更好地加深内镜医护人员对《新指南》的认知和理解,指导患者进行肠道准备,从而最大程度提高肠镜诊疗效果,更大程度的使患者获益。     

结肠镜辅助腹腔镜下直肠息肉切除术治疗直肠息肉的效果

目的探讨结肠镜辅助腹腔镜下直肠息肉切除术治疗直肠息肉的临床效果。方法将我院收治的60例直肠息肉患者根据手术方法不同分为对照组和观察组,各30例。对照组行结肠镜直肠息肉切除术,观察组行结肠镜与腹腔镜下直肠息肉切除术。比较两组的临床效果。结果两组术后第1、3、5天的VAS评分及术中出血量比较,差异不显著(P>0.05)。观察组的手术时间、肛门排气时间、进食恢复时间、住院时间均显著短于对照组(P<0.05)。观察组的并发症总发生率显著低于对照组(P<0.05)。结论在直肠息肉的临床治疗中,给予结肠镜辅助腹腔镜下直肠息肉切除术有助于促进患者的术后恢复,具备临床推广价值。     

Combined MRI and fibreoptic colonoscopy: technical considerations and clinical feasibility

A method of fibre-optic colonoscopy with simultaneous high resolution MRI has been developed to obtain cross-sectional information of the intramural and extramural extent of lesions, for diagnostic and therapeutic purposes. An MR-compatible colonoscope with receiver coil was designed, developed and used in ex vivo studies to scan a section of large bowel in transverse and longitudinal planes with T₁ and T₂ weighted spin-echo sequences. In vivo five patients were followed-up after excision of large bowel cancer. The patients were three men and two women aged 50-77 years, (mean 65.6 years) who were studied on a 0.5 T scanner (Picker Asset, OH, USA). The coil and colonoscope were inserted into the rectum. After routine visual inspection of the colon, T₁ weighted spin-echo images and radio-frequency spoiled gradient-echo images of the bowel wall were obtained. Ex vivo: three layers of bowel wall were identified: an intermediate to high signal-intense mucosa, a high signal intensity layer on T₁ weighting which corresponded to the submucosa, and a low signal intensity muscularis propria. In vivo: On T₁ weighted images three layers could be identified that corresponded to the layers seen on the ex vivo imaging. This pilot study demonstrates that MR colonoscopy is feasible and allows delineation of bowel wall structure, thus providing a useful adjunct to conventional colonscopy.     

A short course of corticosteroids prior to surveillance colonoscopy to decrease mucosal inflammation in inflammatory bowel disease patients: Results from a randomized controlled trial

BackgroundInflammation is a known pitfall of surveillance colonoscopy for inflammatory bowel disease (IBD) as it is difficult to differentiate between inflammation and true dysplasia. This randomized controlled trial assessed the effectiveness of a low dose of corticosteroids prior to surveillance colonoscopy to decrease mucosal inflammation.MethodsIBD-patients scheduled for surveillance colonoscopy between July 2008–January 2010 were eligible to participate. Patients were randomized to either two weeks daily 20 mg prednisone and calcium plus vitamin D prior to surveillance colonoscopy or no treatment. All biopsies were reviewed by an expert gastrointestinal pathologist who was blinded for medication-use. Statistics were performed using chi-square tests, non-parametric tests and binary logistic regression.ResultsSixty patients (M/F 30/30, UC/CD 31/29) participated: 31 (52%) in the treatment arm and 29 (48%) in the control group. In the treatment arm, 247 biopsies were scored against 262 in the control group. In the treatment arm 27 out of 247 biopsies (10.9%) had a score > 1 on the Geboes scale, against 50 out of 262 biopsies (19.1%) in the control group, p = 0.013. In total, 58% of the treatment arm against 66% of the control group had endoscopic or histological mucosal inflammation (p = 0.6). There was a trend for patients in the treatment arm to have less severe inflammation compared with the control group, however this was not significant (p = 0.12).ConclusionsIn our cohort, a short course of corticosteroids decreases the overall histological disease activity in individual biopsies without major side-effects. Moreover, there is a trend for corticosteroids to decrease the maximum severity of both endoscopic and histological disease activity per patient.     

Surveillance after positive colonoscopy based on adenoma characteristics

BackgroundPatients with adenomatous polyps are at increased risk for developing colorectal cancer based on the characteristics and number of polyps, but less is known about the individual and combined contribution of these factors. This study aimed to better characterize the risk of advanced adenoma and cancer in patients with positive baseline colonoscopy.MethodsPatients who had polyps at baseline colonoscopy were included in this retrospective cohort study (N = 1165) and were categorized into 6 groups: (1) 1–2 non-advanced adenomas (NAA’s), (2) ≥3 NAA’s, (3) advanced tubular adenoma, (4) small tubulovillous adenoma (TVA), (5) large TVA and (6) multiple advanced adenomas (MAA’s). Findings at surveillance colonoscopy were documented in each group.ResultsThe combined incidence of advanced adenoma, ≥3 NAA’s, and colorectal cancer at surveillance colonoscopy was significantly higher in the baseline large TVA (29.2%) than small TVA groups (13.5%, P < 0.001), as well as in the MAA’s group (44.1%) compared with large TVA group (P = 0.02). The incidence of colorectal cancer, however, was not significantly different between the groups.ConclusionsThe size of the polyp and the number of advanced lesions are more important than its histology for predicting the risk of high-risk metachronous lesions at follow-up.     

SPLENIC RUPTURE FOLLOWING ROUTINE COLONOSCOPY

Splenic rupture is a life‐threatening condition characterized by internal hemorrhage, often difficult to diagnose. Colonoscopy is a gold standard routine diagnostic test to investigate patients with gastrointestinal symptoms as well as to those on the screening program for colorectal cancer. Splenic injury is seldomly discussed during consent for colonoscopy, as opposed to colonic perforation, as its prevalence accounts for less than 0.1%. A 66‐year‐old Caucasian woman with no history of collagen disorder was electively admitted for routine colonoscopy for surveillance of adenoma. She was admitted following the procedure for re‐dosing of warfarin, which was stopped prior to the colonoscopy. The patient was found collapsed on the ward the following day with clinical shock and anemia. Computed tomography demonstrated grade 4 splenic rupture. Immediate blood transfusion and splenectomy was required. Splenic rupture following routine colonoscopy is extremely rare. Awareness of it on this occasion saved the patient's life. Despite it being a rare association, the seriousness warrants inclusion in all information leaflets concerning colonoscopy and during its consent.     

依托咪酯复合瑞芬太尼在老年患者无痛肠镜检查中的应用

目的研究依托咪酯、瑞芬太尼静脉复合麻醉用于无痛肠镜检查的可行性及安全性。方法择期行肠镜检查且无肠镜检查禁忌证的的患者120例,年龄65～72岁,ASAⅠ或Ⅱ级。随机分为3组,每组40例:E组:静脉推注瑞芬太尼2μg/kg,依托咪酯用量每次0.15～0.3mg/kg;P组:静脉推注瑞芬太尼2μg/kg,异丙酚每次1.5～2.0mg/kg;C组:接受常规肠镜检查。监测并记录患者入室至检查结束不同时点的血氧饱和度(SpO2)、心率(HR)、血压及心电图,观察苏醒时间、镇痛评分(VAS评分)、不良反应并进行比较。结果E组和P组患者顺利完成肠镜检查,患者术中几无不适感,不良反应的发生率较C组低(P<0.05),C组患者反应明显;P组和C组在检查过程中血压、心率变化最大,与检查前相比较均降低或升高15%～25%和20%～35%。E组则变化较小,血压仅降低8%,心率降低6%,与P组和C组比较差异有统计学意义(P<0.05)。P组患者主诉有血管刺激症状12例占30%,而E组患者主诉有血管刺激症状6例占15%,差异具有统计学意义(P<0.05)。结论依托咪酯、瑞苏太尼静脉复合麻醉用于无痛肠镜检查对老年患者是一种安全有效方法。