Acceptability, effectiveness, and cost-effectiveness of internet-based exposure treatment for irritable bowel syndrome in a clinical sample: a randomized controlled trial

Background

A colonoscopy may frequently miss polyps and cancers. A number of techniques have emerged to improve visualization and to reduce the rate of adenoma miss.

Methods

We conducted a randomized controlled trial (RCT) in two clinics of the Gastrointestinal Department of the Sanitas University Foundation in Bogota, Colombia. Eligible adult patients presenting for screening or diagnostic elective colonoscopy were randomlsy allocated to undergo conventional colonoscopy or narrow-band imaging (NBI) during instrument withdrawal by three experienced endoscopists. For the systematic review, studies were identified from the Cochrane Library, PUBMED and LILACS and assessed using the Cochrane risk of bias tool.

Results

We enrolled a total of 482 patients (62.5% female), with a mean age of 58.33 years (SD 12.91); 241 into the intervention (NBI) colonoscopy and 241 into the conventional colonoscopy group. Most patients presented for diagnostic colonoscopy (75.3%). The overall rate of polyp detection was significantly higher in the conventional group compared to the NBI group (RR 0.75, 95%CI 0.60 to 0.96). However, no significant differences were found in the mean number of polyps (MD -0.1; 95%CI -0.25 to 0.05), and the mean number of adenomas (MD 0.04 95%CI -0.09 to 0.17). Meta-analysis of studies (regardless of indication) did not find any significant differences in the mean number of polyps (5 RCT, 2479 participants; WMD -0.07 95% CI -0.21 to 0.07; I2 68%), the mean number of adenomas (8 RCT, 3517 participants; WMD -0.08 95% CI -0.17; 0.01 to I2 62%) and the rate of patients with at least one adenoma (8 RCT, 3512 participants, RR 0.96 95% CI 0.88 to 1,04;I2 0%).

Conclusion

NBI does not improve detection of colorectal polyps when compared to conventional colonoscopy (Australian New Zealand Clinical Trials Registry ACTRN12610000456055).     

A randomized crossover open trial of the adenoma miss rate for narrow band imaging (NBI) versus flexible spectral imaging color enhancement (FICE)

Purpose

Narrow band imaging (NBI) and flexible spectral imaging color enhancement (FICE) allow improved contrasted evaluation of the mucosal surface. However, no study has compared the utility of these two modalities. Therefore, the aim of this study was to compare the adenoma miss rate (AMR) between NBI and FICE.

Methods

A total of 55 patients (38 men, 17 women) were enrolled in this study. Patients were randomly assigned to the NBI–FICE group (NBI followed by FICE) or the FICE–NBI group (FICE followed by NBI). NBI and FICE total colonic observations were tandemly performed for each patient during the scope withdrawal with white light following cecal intubation. All detected polyps with the NBI or FICE observation were categorized into three groups according to the size and number of polyps missed.

Results

Twenty-nine patients were assigned to the NBI–FICE group, and 26 patients were assigned to the FICE–NBI group. There was no significant difference in the overall AMR when comparing the image-enhanced endoscopy technologies (17.9 % for NBI, 26 % for FICE, p?=?0.159). AMR was lower for NBI than for FICE for adenomas <5 mm in diameter (5.7 % for NBI, 12.6 % for FICE, p?=?0.036). AMR was not significantly different when comparing NBI and FICE for lesions 5 to 10 mm (p?=?0.967) or for lesions ≥10 mm (p?=?0.269).

Conclusions

This study demonstrated that overall AMR was not different when comparing NBI and FICE.     

Does Magnifying Narrow-Band Imaging or Magnifying Chromoendoscopy Help Experienced Endoscopists Assess Invasion Depth of Large Sessile and Flat Polyps?

Background

Distinguishing deep submucosa (SM) from superficial SM cancer in large sessile and flat colorectal polyps (>2 cm) is crucial in making the most appropriate therapeutic decision. We evaluated the additional role of magnifying narrow-band imaging (NBI) and magnifying chromoendoscopy (MCE) in assessing the depth of invasion in large sessile and flat polyps in comparison to morphological evaluation performed by experienced endoscopists.

Methods

From May 2011 to December 2011, a total of 85 large sessile and flat polyps were analyzed. Endoscopic features of the polyps were independently evaluated by experienced endoscopists. Subsequently, the polyps were observed using magnifying NBI and MCE.

Results

A total of 58 intramucosal lesions and 27 SM cancers (five superficial and 22 deep) were identified. The diagnostic accuracy of the experienced endoscopists, NBI, and MCE were 92.9, 90.6, and 89.4 %, respectively, for deep SM cancer. In combination with NBI or MCE, the diagnostic accuracy of the experienced endoscopists did not change significantly for deep SM cancer, with an accuracy of 95.3 % for both NBI and MCE.

Conclusions

Conventional colonoscopy can differentiate superficial from deep SM cancers with an accuracy of as high as 92.9 % in large sessile and flat polyps. Further diagnostic strategies are required in order to precisely assess the depth of invasion, especially in large colorectal polyps.     

Narrow-band imaging colonoscopy--a pilot feasibility study for the detection of polyps and correlation of surface patterns with polyp histologic diagnosis

BACKGROUND: Colonoscopy is the preferred screening method for colorectal cancer. However, it has a substantial miss rate for colon polyps, and several techniques have been attempted to improve this limitation. Narrow-band imaging (NBI) is a novel technology that enhances the visualization of surface mucosal and vascular patterns. OBJECTIVE: The aim of this study was to determine the detection rate of additional polyps by NBI after removal of polyps visualized by standard white light colonoscopy (WLC) and to correlate the surface mucosal and vascular patterns with polyp histologic diagnosis. DESIGN: This was a prospective pilot feasibility study. SETTING: Kansas City Veterans Affairs Medical Center. PATIENTS: Subjects referred for screening colonoscopy were prospectively enrolled. METHODS: Subjects underwent colonoscopy after enrollment. After intubation of the cecum, colonic segments were sequentially examined, initially with WLC with removal of polyps followed by re-examination of the same segment with NBI. Additional polyps seen with NBI were photographed for their surface patterns and then removed. The total number of polyps visualized by WLC and NBI was calculated and the surface patterns were then correlated with polyp histologic features. RESULTS: Forty patients were enrolled in the study, all men, 32 white. The mean age was 62 years. A total of 72 polyps were detected by WLC (43 tubular adenoma, 28 hyperplastic polyps), whereas NBI detected an additional 51 polyps, of which 29 were tubular adenomas and 22 were hyperplastic. Five different surface/vascular patterns were observed: fine capillary network with absent mucosal pattern, circular pattern with dots, round/oval pattern, tubular pattern, and gyrus pattern. The sensitivity, specificity, and overall accuracy of the first two patterns for hyperplastic polyps were 86%, 96%, and 92%, respectively, and of the latter three patterns for tubular adenomas were 96%, 86%, and 92%, respectively. CONCLUSIONS: This pilot study demonstrates the feasibility of polyp detection and histologic correlation with NBI. These findings need to be confirmed in future randomized controlled trials.     

Efficacy of magnifying endoscopy with flexible spectral imaging color enhancement in the diagnosis of colorectal tumors

Background

Magnifying endoscopy with flexible spectral imaging color enhancement (FICE) is an image-enhanced endoscopy that captures the surface and vascular patterns of colorectal tumors. We evaluated and compared FICE magnification to narrow-band imaging (NBI) magnification.

Methods

Flexible spectral imaging color enhancement or NBI magnification was performed to the visualize surface and vascular patterns of colorectal tumors, classified into 4 types: Type A, Type B, Type C1/C2, and Type C3, as previously reported. A total of 235 colorectal tumors were examined. The correlations between classifications found by FICE or NBI magnification and histopathological diagnoses were examined. Image evaluation was validated by assessing inter-observer and intra-observer agreements on examinations.

Results

Twenty-eight hyperplastic polyps (HPs), 115 tubular adenomas (TAs), 72 mucosal and slightly invaded submucosal cancers (M-sSM), and 20 massively invaded submucosal cancers (mSM) were diagnosed. By FICE magnification, HP and TA were observed in 93.3 and 6.7% of Type A (15 lesions), respectively. TA, M-sSM, and HP were observed in 82.6, 15.4, and 2.0% of Type B (52 lesions), respectively. M-sSM, TA, and mSM were observed in 50.0, 46.0, and 4.0% of Type C1/2 (50 lesions), respectively. mSMs were observed in all 7 Type C3 lesions. In diagnosing mSM in Type C3, the sensitivity and specificity of FICE magnification were 77.7 and 100%, respectively, compared to those of NBI, at 63.6 and 99.0%, respectively. Imaging evaluation was validated accurately by intra- and intra-observer measurements showing consistent results.

Conclusions

The classification of colorectal tumors by FICE magnification correlated well with the histopathological diagnoses, similar to findings for NBI magnification. FICE magnification can be evaluated accurately with the same diagnostic classifications as those used for NBI magnification.     

Detection rate and proximal shift tendency of adenomas and serrated polyps: a retrospective study of 62,560 colonoscopies

Purpose

The purpose of this study is to estimate the detection rates of adenomas and serrated polyps and to identify proximalization and associate risk factors in patients from Southern China.

Methods

Consecutive patients undergoing colonoscopy from 2004 to 2013 in Guangzhou were included. The proportions of proximal adenomas to advanced adenomas and serrated polyps were compared and potential predictors were evaluated.

Results

Colonoscopies (n?=?62,560) were performed, and 11,427 patients were diagnosed with polyps. Detection rates for adenomas, hyperplastic polyps, and serrated adenomas were 12.0, 2.5, and 0.2 patients per 100 colonoscopies. When comparing the 1st (2004–2008) to the 2nd period (2009–2013), adenoma and serrated polyp detection in proximal and distal colon both increased significantly (proximal colon [adenoma 3.9 vs. 6.1 patients/100 colonoscopies, P?<?0.001; serrated polyp 0.4 vs. 1.1 patients/100 colonoscopies, P?<?0.001]; distal colon [adenoma 6.6 vs. 7.2 patients/100 colonoscopies, P?=?0.003; serrated polyp 1.2 vs. 2.4 patients/100 colonoscopies, P?<?0.001]). Advanced adenoma detection increased over these two periods only in proximal colon (1st vs. 2nd period: 1.5 vs. 2.4 patients/100 colonoscopies, P?<?0.001), not the distal colon (P?=?0.114). Multivariate analyses showed that diagnostic period was an independent predictor for adenoma proximalization (OR?=?1.36, 95% CI 1.25–1.48, P?<?0.001), but not for advanced adenomas (P?=?0.117) or serrated polyps (P?=?0.928).

Conclusions

Adenomas and serrated polyps were increasingly detected throughout the colon, whereas advanced adenomas were only in proximal colon. A proximal shift tendency detected by colonoscopy was observed for adenomas, but not advanced adenomas or serrated polyps, in Southern China. The screening for proximal polyps should be emphasized and colonoscopy might be a preferred initial screening tool.

     

Effect of Pronase Premedication on Narrow-Band Imaging Endoscopy in Patients with Precancerous Conditions of Stomach

Background

Narrow-band imaging (NBI) endoscopy improves the detection of intestinal metaplasia. However, strategies to improve the visibility and diagnostic performance of NBI should be sought, as endoscopic views are often obscured by the presence of mucus.

Aim

To compare the visibility and diagnostic performance of NBI endoscopy according to pronase premedication in patients with precancerous conditions of the stomach.

Methods

Consecutive outpatients with a previous diagnosis of precancerous condition of the stomach were invited to undergo a surveillance NBI endoscopy between June and December 2012. Enrolled subjects were randomly assigned to pronase or control groups before NBI endoscopy. The visibility score and diagnostic performance of NBI endoscopy were compared between the two groups.

Results

Patients’ endoscopic and histopathological characteristics were similar between the two groups. Visibility score in the proximal part of the stomach and satisfaction score of the endoscopist were significantly higher in the pronase group than in the control group (p = 0.014 and p = 0.034, respectively). The diagnostic performance of NBI endoscopy to detect intestinal metaplasia was not different in either group (both p > 0.1). However, the negative predictive value of NBI endoscopy was much improved over that of white light endoscopy only in the pronase group (p = 0.013).

Conclusion

Pronase premedication increased the visibility of the proximal part of the stomach and the satisfaction score during NBI endoscopy. Furthermore, negative predictive value of NBI endoscopy was much improved compared with that of white light endoscopy after pronase premedication.     

Transanal endoscopic microsurgery for giant polyps of the rectum

Background

The potential for malignancy in rectal polyps increases with the size of the polyp, and unexpected malignancy is reported in up to 39 % of large rectal adenomas. Transanal endoscopic microsurgery (TEM) offers the possibility of an en bloc full-thickness excision for lesions in the rectum. We present our results with TEM in the removal of giant polyps equal or greater than 4 cm in diameter.

Methods

In the period between 1998 and 2012, TEM was performed in 39 patients with rectal polyps measuring at least 4 cm in diameter. Transrectal ultrasound and/or magnetic resonance imaging of the rectum was used when cancer was suspected.

Results

The polyp was removed with en bloc full-thickness excision in 77 % (n = 30). The preoperative diagnosis was benign rectal adenoma in 89.7 % (n = 35). The median size of the polyps was 30 cm² (range 16–100 cm²). Postoperative complications included bleeding in 4 patients (10.3 %). Histological examination showed unexpected cancer in 4 patients (10.3 %). TEM was curative in 2 of these patients, and the other 2 underwent further surgery. Recurrences occurred in 10 patients (25.6 %) and consisted of 5 adenomas and 5 adenocarcinomas. In 5 patients, these recurrences were treated with endoscopic removal or re-TEM. The remaining 5 underwent total mesorectal excision and/or chemotherapy.

Conclusions

Full-thickness TEM provides a safe and efficient treatment for excision of giant polyps. In case of unexpected cancer, TEM can be curative. Local recurrence can be often treated with a second TEM procedure.     

An australian audit of vaccination status in children and adolescents with inflammatory bowel disease

Background

Pre-existing polyps, especially large polyps, are known to be the major source for colorectal cancer, but there is limited available information about factors that are associated with polyp size and polyp growth. We aim to determine factors associated with polyp size in different age groups.

Methods

Colonoscopy data were prospectively collected from 67 adult gastrointestinal practice sites in the United States between 2002 and 2007 using a computer-generated endoscopic report form. Data were transmitted to and stored in a central data repository, where all asymptomatic white (n = 78352) and black (n = 4289) patients who had a polyp finding on screening colonoscopy were identified. Univariate and multivariate analysis of age, gender, performance site, race, polyp location, number of polyps, and family history as risk factors associated with the size of the largest polyp detected at colonoscopy.

Results

In both genders, size of the largest polyp increased progressively with age in all age groups (P < .0001). In subjects ≥ 80 years the relative risk was 1.55 (95% CI, 1.35-1.79) compared to subjects in the youngest age group. With the exception of family history, all study variables were significantly associated with polyp size (P < .0001), with multiple polyps (≥ 2 versus 1) having the strongest risk: 3.41 (95% CI, 3.29-3.54).

Conclusions

In both genders there is a significant increase in polyp size detected during screening colonoscopy with increasing age. Important additional risk factors associated with increasing polyp size are gender, race, polyp location, and number of polyps, with polyp multiplicity being the strongest risk factor. Previous family history of bowel cancer was not a risk factor.     

An endoscopic training model to improve accuracy of colonic polyp size measurement

Purpose

Most studies of colonic polyps rely on visual estimation when regarding polyp size; however, the reliability of a visual estimate is questionable. Our study aims to develop a training model to improve the accuracy of size estimation of colonic polyps in vivo.

Methods

Colon polyps were recorded on 160 video clips during colonoscopy. The size of each polyp was estimated by visual inspection and subsequently measured with a flexible linear measuring probe. The study included a pretest, an intervention, and a posttest. The pretest included 160 video clips, which comprised the visual-estimation portion of the study. The intervention was an educational model consisting of 30 video clips which included a visual-estimation section and a linear-measuring-probe section, designed to help the endoscopists to compare their visual estimate of size with the measured size of the polyps. The posttest included the 160 video clips used in the pretest, presented in random order. Intraobserver agreement and diagnostic accuracy were compared before and after the training session.

Results

Eight beginners and four experienced colonoscopists were enrolled. The overall kappa (κ) values of intraobserver agreement for pretest and posttest were 0.74 and 0.85 for beginner group as well as 0.83 and 0.88 for experienced group, respectively. The overall diagnostic accuracy improved from 0.52 to 0.78 for beginner group and 0.71 to 0.87 for experienced group (P?<?0.05) after education with the training model.

Conclusions

This training model could help endoscopists improve the accuracy of measurement of polyps on colonoscopy in a short period. The durability of learning effect needs further investigation.     

The ability of a novel blue laser imaging system for the diagnosis of invasion depth of colorectal neoplasms

Background

Fujifilm has developed a novel endoscope system with two kinds of lasers that enables us to allow narrow-band light observation with blue laser imaging (BLI). The aim of this study was to evaluate BLI magnification in comparison with narrow-band imaging (NBI) magnification for the diagnosis of colorectal neoplasms.

Methods

This was a multicenter open study. A total of 104 colorectal neoplasms were examined with BLI and NBI magnifications in Kyoto Prefectural University of Medicine and Fukuoka University Chikushi Hospital. Vascular and surface patterns of tumors under BLI magnification were compared with those under NBI magnification, using a published NBI classification. The main outcome was the correlation between the NBI classification diagnosed by BLI or NBI magnification and the histopathological analyses.

Results

Sixty-two cases of adenoma, 34 cases of intramucosal cancer and shallowly invaded submucosal cancer, and eight cases of deeply invaded submucosal cancer were diagnosed. The diagnostic accuracy of BLI magnification in the NBI classification was 74.0 % (77/104), similar to that of NBI magnification (77.8 %). The consistency rate between BLI and NBI magnification in the NBI classification was 74.0 %. Concerning image evaluation, the interobserver variability of two expert endoscopists (N.Y. and T.H.) in BLI magnification was κ = 0.863. On the other hand, the intraobserver variability of the two endoscopists was κ = 0.893 (N.Y.) and 0.851 (T.H.).

Conclusions

BLI magnification by laser source could predict histopathological diagnosis and invasion depth of colorectal neoplasms. The diagnostic effectiveness of this method was similar to that of NBI magnification.     

Phenotypic diversity in patients with multiple serrated polyps: a genetics clinic study

Objective

Hyperplastic polyposis is a colonic polyposis condition of unknown aetiology. The purpose of this study was to examine the spectrum of phenotypic variation in patients with multiple serrated polyps as a basis for gene discovery.

Methods

One hundred and twenty-six patients with multiple (≥5) serrated polyps were recruited to the study. Polyp counts were extracted from histology and colonoscopy reports. Ethnicity was self-reported. Family history of cancer data were derived from pedigrees. Ascertainment status was classified as either index case or identified by screening.

Results

The average reported polyp count was 39. Patients with highest polyp numbers were more likely to be male (P? =?0.02). Colorectal cancer (CRC) was identified in 49 of 119 patients (41%) and 28% of these patients had multiple CRC. Young onset patients had higher polyp numbers (P? =?0.03) and were more likely to have their CRC in the distal colon (P? =?0.02). CRC was significantly associated with the presence of adenomas (P? =?0.03). Patients were divided into moderate polyposis (5-79 serrated polyps) and dense polyposis (80 or more) categories. The dense polyposis category was associated with a lack of family history for CRC (P? =?0.034) and male gender (P? =?0.014), independent of ascertainment status and recruitment site.

Conclusion

Multiple serrated polyps were associated with an increased personal risk of CRC. A subset of patients with the highest polyp numbers was more likely to be male and to have no family history of CRC. This result suggests heterogeneous modes of inheritance and has implications for studies investigating the genetic basis of multiple serrated polyps.     

Narrow band imaging versus white light gastroscopy in detecting potentially premalignant gastric lesions: a randomized prospective crossover study

Background and Aims

Narrow band imaging (NBI) detects mucosal surface details (pit pattern) as well as the microvasculature pattern of mucosa. In premalignant conditions the pattern and regularity of pits and microvasculature are altered. We aimed to assess whether NBI is superior to conventional white light gastroscopy (WLG) in detecting potentially premalignant gastric lesions.

Patients and Methods

We conducted a randomized prospective crossover study from January 2009 to July 2009. Patients above 45 years of age with dyspepsia in absence of alarm symptoms underwent gastric mucosal examination using WLG and NBI in the same session by different endoscopists who were blinded to each other’s endoscopy findings. Biopsy was taken if required at the end of the second gastroscopy after a third observer reviewed reports of both scopists. The yield of gastric potentially premalignant lesions (atrophic gastritis, intestinal metaplasia, dysplasia, adenomatous polyp) was compared for both procedures.

Results

Two hundred [mean age 52.3 (6.4) years, males-66 %] patients participated in the study. Thirty-two patients were diagnosed to have potentially premalignant lesions using both modalities. No patient had early gastric cancer. WLG detected lesions in 17 patients (atrophic gastritis in 12, atrophic gastritis with intestinal metaplasia in 5) and NBI in 31 patients (atrophic gastritis in 22, atrophic gastritis with intestinal metaplasia in 9). The sensitivity of lesion detection by NBI was significantly higher than WLG (p?=?0.001).

Conclusions

NBI was superior to WLG for detection of atrophic gastritis and intestinal metaplasia.     

Endoscopic evaluation of the colon after an episode of diverticulitis: a call for a more selective approach

Purpose

Routine colonic evaluation is advised after an episode of diverticulitis to exclude colorectal cancer. In the recent years, the possible relation between diverticulitis and colorectal cancer has been subject of debate. The aim of this study is to evaluate the benefit of routine colonic endoscopy after an episode of diverticulitis.

Methods

Records of all consecutive patients presenting with a radiologically confirmed episode of diverticulitis between 2007 and 2010 were retrieved from an in-hospital database. Patients who subsequently underwent colonic evaluation were included. The endoscopic detection rate of hyperplastic polyps, adenomas and advanced colonic neoplasia was assessed. Findings were categorized on the basis of the most advanced lesion identified.

Results

Three hundred and seven patients presented with a radiologically confirmed primary episode of diverticulitis. Two hundred and five patients underwent colonic evaluation. Hyperplastic polyps were found in15 (6.8?%), adenomas in 18 (8.8?%) and advanced neoplastic lesions in 7 (3.4?%) patients. Only two patients had a colorectal malignancy.

Conclusion

There appears to be no benefit in performing routine colonic evaluation after an episode of diverticulitis as the incidence of colorectal cancer is almost equal to that of the general population. A more selective approach might therefore be justified. Potentially, only patients with persisting abdominal complaints after an episode of diverticulitis should be offered colonic evaluation to definitively exclude causal pathology.     

Frequency of colonic adenomatous polyps in a tertiary hospital in Mumbai

Introduction

Incidence of colorectal carcinoma is increasing all over world. There is limited data on colorectal polyps from India. We evaluated the histomorphological features of colorectal polyps and determined risk stratification in adenomatous polyps.

Methods

In 4970 consecutive colonoscopies, colorectal polyps were detected in 515 cases (10.3 %). Polyps were classified using standard histological criteria. Each polyp was evaluated for presence of dysplasia. Adenomatous polyps were classified as low-risk adenomas (1–2 tubular adenomas <10 mm) and high-risk adenomas characterized by villous histology, high-grade dysplasia, size ≥10 mm, or ≥3 adenomas.

Results

Of 515 colorectal polyps, 270 (52.4 %) were adenomatous, followed by 78 (15.1 %) inflammatory, 78 (15.1 %) hyperplastic, 32 (6.2 %) hamartomatous polyps, 25 (4.8 %) benign epithelial polyps, 5 (0.9 %) cap polyps, 5 (0.9 %) lipomatous polyps, 3 (0.5 %) angiomatous polyps, 4 (0.7 %) lymphoid, and 15 (2.9 %) cases with adenocarcinoma masquerading as polyps. Mean (SD) age with colorectal polyps was 54.8?(33.0)?years while for adenomatous polyps, 59.5?(14.8)?years with male to female ratio of 2:1. Majority of adenomatous polyps 124 (45.9 %) were tubular adenomas present in rectosigmoid. High-grade dysplasia was found in 38 (14 %) adenomas. One hundred and fifty-five (57.4 %) were high risk of which majority were villous adenomas and nine (7.2 %) tubular adenomas.

Conclusion

The most common colorectal polyps found during routine colonoscopy were 270 adenomatous (52.4 %) cases. Of these, 155 (57.4 %) adenomatous polyps were high-risk category. Population prevalence data of colonic polyps in general population beyond the age of 50 years needs to be obtained.

     

High-Definition White-Light (HDWL) Colonoscopy and Higher Adenoma Detection Rate and the Potential for Paradoxical Over Surveillance

Background

Patients undergoing high-definition white-light colonoscopy by a high adenoma detector may have a lower risk of interval adenoma detection on follow-up colonoscopy and may require less frequent follow-up but may paradoxically be assigned to more frequent surveillance when more adenomas are detected.

Aims

To evaluate whether high-definition white-light colonoscopy (vs. standard-definition white-light colonoscopy) and endoscopist adenoma detection rate (ADR) at index colonoscopy are associated with increased likelihood of adenomas at follow-up.

Methods

Longitudinal follow-up of prior cross-section cohort study of patients who underwent colonoscopy at baseline with at least one detected adenoma was included. Associations of type of white-light at index colonoscopy and the ADR of the endoscopist at index colonoscopy (high vs. low adenoma detector) were evaluated with various adenoma and polyp detection endpoints. Eighteen endoscopists were classified as high and low adenoma detectors based on the median ADR of 0.255.

Results

There were no significant differences in subsequent interval adenoma or polyp detection endpoints with regard to whether baseline exam was performed with high-definition white-light or standard-definition white-light colonoscopy nor between high and low ADR after adjusting for multiple testing (P ≤ 0.0029 considered significant). Prior to multiple testing adjustment, there was a significantly lower detection rate of hyperplastic polyps in the left colon (24 vs. 35 %, OR: 0.56, P = 0.033) at follow-up colonoscopy when baseline exam was performed with high-definition white-light index colonoscopy.

Conclusions

The results of this study do not support adjusting colonoscopy surveillance guidelines based on type of colonoscopy performed or the endoscopist’s ADR.     

Endoclip-Assisted Resection of Large Pedunculated Colorectal Polyps: Technical Aspects and Outcome

Background

The most common complication of polypectomy is hemorrhage, and various techniques have been used to prevent this complication.

Aim

This study evaluates the outcomes of endoclip-assisted polypectomy in patients with large pedunculated colorectal polyps, in comparison with a historical control group of patients treated with endoloop-assisted polypectomy.

Methods

Between January and December 2007, 32 patients with 32 large pedunculated polyps (≥15 mm) were treated with endoclip-assisted polypectomy (group A). Between January and December 2006, 35 patients with 35 large pedunculated polyps were treated; 33 with endoloop-assisted polypectomy (control, group B) and two cases with endoclips and needle knife, which were included in group A for the analysis.

Results

The mean (± standard deviation [SD]) size of polyp head was 26.8 ± 8.1 mm (range 15–50) in group A and 22.3 ± 4.1 mm (range 15–30) in group B (P = 0.004). In group A, six polyps had a mean (±SD) head size of 40.8 ± 5.8 mm (range 35–50) and were resected with clips and needle knife. In group A, bleeding occurred in two cases (5.9%), which were associated with the presence of cancer at histology (P = 0.006) and were managed by applying new clips. No bleeding occurred in patients of group B and no perforation and post-polypectomy syndrome occurred in either group. There were three (8.8%) cancerized adenomas in group A and one (3%) in group B. Clip application was possible in all patients, while in two cases, loop placement was impossible.

Conclusions

In our experience, endoclip-assisted resection is a safe alternative to endoloop for the resection of large pedunculated colorectal polyps when endoloop placement is difficult or impossible.     

Rationale for and clinical benefits of colonoscopy with narrow band imaging: pathological prediction and colorectal screening

Introduction

Narrow-band imaging (NBI), an emerging imaging technology, allows direct visualization of capillaries on the gastrointestinal mucosal surface. The combination of NBI and magnifying endoscopy can be used to identify morphological changes in these capillaries during the process of carcinogenesis.

Findings and conclusions

Thus far, pathological predictions based on capillary pattern classifications have been reported to have good diagnostic accuracy. However, most of these studies have been single-center trials based on each institutional classification, and worldwide multicenter trials aimed at their standardization are needed to validate the clinical benefits of the various NBI classification systems.     

The risk of advanced histology in small-sized colonic polyps: are non-invasive colonic imaging modalities good enough?

Purpose

The study aims to evaluate the risk of advanced histology within small colonic polyps and assess whether this risk warrants different recommendation for surveillance and treatment of such polyps.

Methods

A retrospective study of all patients undergoing their first ever colonoscopy and polypectomy in a tertiary hospital for one of three indications: screening, positive family history, and positive occult blood in stool. The histological reports of all resected polyps were retrieved and stratified according to the various polyps’ sizes. Advanced neoplasia was defined as tubular adenoma ≥10?mm or any size polyp with advanced histology, i.e., villous or tubulovillous adenoma, high-grade dysplasia, intramucosal carcinoma, or invasive cancer.

Results

Seven hundred forty-one patients who had a total of 1,192 resected polyps were included. Of polyps ≤5?mm in size, 1.6% harbored invasive cancer or high-grade dysplasia, and additional 4.1% contained villous component. The rate of advanced histology for polyps sized 6–9?mm was over 15%. The rate of advanced histology in polyps ≤5?mm was not significantly different when employing sensitivity analysis accounting for possible under or overestimation of polyp sizes by 1 and 2?mm. However, 4.6% of polyps sized 6–9?mm were found to harbor an invasive or high-grade dysplasia component when taken into account a 2-mm overestimation.

Conclusions

A non-negligible fraction of small polyps harbor advanced histology. This finding suggests that expectant follow-up by non-invasive colonic imaging modalities for small polyps or not reporting them may put more than 5% of patients at risk of dysplasia progression.     

Portal hypertensive polyps: distinct entity

Introduction

Gastric mucosal changes in portal hypertension (PH) are well known, but gastroduodenal polyps in PH are rarely described.

Aim

This study aims to estimate prevalence of upper gastrointestinal (GI) polyps in patients with PH of any etiology and to evaluate the role of angiogenesis in portal hypertensive polyps.

Material and Methods

This is a retrospective analysis of all patients undergoing upper GI endoscopy to compare the etiology of the polyps in the portal hypertensive group vs. those without PH. The diagnosis of polyps was done using standard histological criteria. Another part of the study consisted of prospective analysis of vascular proliferative marker CD 34 and morphometry in 47 patients.

Results

A total of 3,811 upper GI endoscopies were done of which 121 patients (3.2 %) had polyps in upper GI tract. In patients with PH (=631), polyps were noted in 16, portal hypertensive polyps in 9, hyperplastic in 6, and fundic gland polyp in 1. In the patients without PH (n?=?3,180), polyps of various etiologies were noted in 105 patients. The prevalence of polyps of all causes was similar in both groups (2.5 % vs. 3.3 %, p?=?0.3957). Prevalence of hyperplastic polyps was similar in PH (0.95 %) and non-PH group (1.3 %). On immunohistochemistry, PH polyps and PH gastric mucosa had significantly higher vessel diameter of >50 μm, increased vascular density as compared to non-portal hypertensive polyps (PHP) and normal gastric mucosa.

Conclusion

PHP are definite identifiable lesion in patients of cirrhosis with PH. PHP are probably related to increased angiogenesis in gastric mucosa.