The mean number of adenomas per procedure should become the gold standard to measure the neoplasia yield of colonoscopy: A population-based cohort study

BackgroundMeasuring adenoma detection is a priority in the quality improvement process for colonoscopy. Our aim was (1) to determine the most appropriate quality indicators to assess the neoplasia yield of colonoscopy and (2) to establish benchmark rates for the French colorectal cancer screening programme.MethodsRetrospective study of all colonoscopies performed in average-risk asymptomatic people aged 50–74 years after a positive guaiac faecal occult blood test in eight administrative areas of the French population-based programme.ResultsWe analysed 42,817 colonoscopies performed by 316 gastroenterologists. Endoscopists who had an adenoma detection rate around the benchmark of 35% had a mean number of adenomas per colonoscopy varying between 0.36 and 0.98. 13.9% of endoscopists had a mean number of adenomas above the benchmark of 0.6 and an adenoma detection rate below the benchmark of 35%, or inversely. Correlation was excellent between mean numbers of adenomas and polyps per colonoscopy (Pearson coefficient r = 0.90, p < 0.0001), better than correlation between mean number of adenomas and adenoma detection rate (r = 0.84, p = 0.01).ConclusionThe mean number of adenomas per procedure should become the gold standard to measure the neoplasia yield of colonoscopy. Benchmark could be established at 0.6 in the French programme.     

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.     

One or two operator technique and quality performance of colonoscopy: A randomised controlled trial

BackgroundThe two-operator technique for colonoscopy, with the endoscopy assistant actively advancing and withdrawing the scope, is still commonly practiced in Europe. As uncontrolled data has suggested that the one-operator technique is associated with a higher adenoma detection rate, we tested the hypothesis that the two-operator-technique can achieve comparable performances in terms of adenoma detection.MethodsNon-inferiority trial in which consecutive adult outpatients were randomised to undergo colonoscopy by one (one-operator) or by four endoscopists. Each performed half the procedures by one-operator and half by two-operator technique independently of routine clinical practice. Main outcome measure was adenoma detection rate.Results352 subjects (49% males, mean age 60 ± 12.1 years) were randomised to one (n = 176) or to two-operator technique (n = 176) colonoscopy. No significant differences were found in adenoma detection (33% vs. 30.7%, p = 0.65), or cecal intubation rate, procedure times, and patient tolerability. No differences were found in the subgroup analysis according to routinely adopted colonoscopy technique.ConclusionsThis study does not confirm a higher adenoma detection rate for one-operator technique colonoscopy. Changing current practice to improve adenoma detection rate for endoscopists routinely using two-operator technique is not warranted.     

Computed tomographic colonography in subjects with positive faecal occult blood test refusing optical colonoscopy

BackgroundRefusal of colonoscopy is a drawback of colorectal cancer screening programmes based on faecal occult blood test. Computed-tomographic-colonography is generally more accepted than colonoscopy.AimTo compare adherence to computed-tomographic-colonography and second-invitation colonoscopy in subjects with positive faecal test refusing colonoscopy.MethodsWe performed a prospective study in 198 subjects with positive faecal test who refused first referral to colonoscopy in one endoscopy service of the Florence screening programme. Subjects were randomly invited to computed-tomographic-colonography (n = 100) or re-invited to colonoscopy (n = 98). Mail invitation was followed by a questionnaire administered by phone. Computed-tomographic-colonography findings were verified with colonoscopy.Results32 subjects could not be reached, 71 (35.9%) had undergone colonoscopy on their own; 4 were excluded for contraindications; 30/48 (62.5%) in the computed-tomographic-colonography arm and 11/43 (25.6%) in the colonoscopy arm accepted the proposed examinations (p < 0.001). Four advanced adenomas and 1 cancer were found in the 28 subjects who ultimately underwent computed-tomographic-colonography and 2 advanced adenomas and 2 cancers in the 9 subjects who ultimately underwent second-invitation colonoscopy.ConclusionSubjects with positive faecal occult blood test refusing colonoscopy show a higher adherence to computed-tomographic-colonography than to second invitation colonoscopy.     

Positive predictive value of fecal immunochemical test for high-risk colonic adenomas and carcinoma: A health maintenance organization cohort screening study in Lebanon

Background and Study AimsFecal Immunochemical Test (FIT) is one of the leading modalities for colorectal cancer screening. Studies show that FIT is highly sensitive for the detection of colorectal cancer (CRC) but not similarly accurate for detection of pre-cancerous advanced adenomas (AA). We studied the performance metrics of FIT for the detection of CRC and AA in a health maintenance organization (HMO) cohort screening program.Patients and MethodsRetrospective cohort study of asymptomatic persons of screening age belonging to a HMO. Endoscopy and pathology reports of those who tested positive were used to calculate the positive predictive value (PPV) of FIT, and characterize endoscopic findings on colonoscopy.ResultsBetween 1995 and 2017, 3000 persons had screening fecal occult testing as part of their Employee Health Care plan. Of those, 150 had a positive qualitative FIT (cutoff 10 Âµg hemoglobin/g feces). All underwent colonoscopy, and median time to colonoscopy was 27 days. 4 (2.6%) had carcinoma (2 stage IIIA and 2 stage IIIB), 106 (70.6%) had adenomas of which 40 (26.6% of the total cohort) had advanced adenomas (≥1 cm, villous features, or high-grade dysplasia) giving a PPV for AA and carcinoma of 29% and 3% respectively. When stratified by age, the PPV of AA; carcinoma was [50–59 (21.7%; 0.0%)], [60–69 (14.6%; 4.2%)], [70–79 (42.6%; 2.1%)], [80–89 (33.3%; 11.1%)].ConclusionThe performance characteristics of FIT testing are acceptable for population screening in resource-limited settings. The results of this study are helpful when discussing expectations prior to colonoscopy in people with positive FIT.     

Impacto del proceso de enseñanza endoscópica en la detección de adenomas colónicos

BackgroundThere has been little reported experience in the Latin American hospital setting in relation to the impact of the endoscopic training process on colonoscopy quality.AimsTo determine the effect that training in the technique of colonoscopy has on adenoma detection in an Argentinian teaching hospital.Material and methodWithin the time frame of July 2012 and July 2013, 3 physicians received training in colonoscopy from 4 experienced endoscopists. The colonoscopies performed by the supervised trainees were compared with those carried out by the experienced endoscopists.ResultsA total of 318 colonoscopies performed by any one of the 3 supervised trainees and 367 carried out by any one of the experienced endoscopists were included. The univariate analysis showed a non-significant difference in the detection rate of adenomas (30.4 vs. 24.7%, P = .09). In the multivariate analysis, the detection rate of adenomas was significantly higher in the colonoscopies performed by one of the 3 trainees (odds ratio = 1.72 [1.19-2.48]).ConclusionsThe supervised involvement of endoscopic trainees has a positive effect on adenoma detection.     

Development of knowledge-based clinical decision support system for patients included in colorectal screening program

Background & aimsColorectal (CRC) screening programs represent a large volume of procedures that need a follow-up endoscopy. A knowledge-based clinical decision support system (K-CDSS) is a technology which contains clinical rules and associations of compiled data that assist with clinical decision-making tasks. We develop a K-CDSS for management of patients included in CRC screening and surveillance of colorectal polyps.MethodsWe collected information on 48 variables from hospital colonoscopy records. Using DILEMMA Solutions Platform © (https://www.dilemasolution.com) we designed a prototype K-CDSS (PoliCare CDSS), to provide tailored recommendations by combining patients data and current guidelines recommendations. The accuracy of rules was verified using four scenarios (normal colonoscopy, lesions different than polyps, non-advanced adenomas and advanced adenomas). We studied the degree of agreement between the clinical assessments made by expert doctors and nurses equipped with PoliCare CDSS. Two experts confirmed a correlation between guidelines and PoliCare recommendations.Results56 consecutive endoscopy cases from colorectal screening program were included (62.8 years; range 53-71). Colonoscopy results were: absence of colon lesions (n = 7, 12.5%), lesions in the colon that are not polyps (n = 3, 5.4%) and resected colonic polyps (n = 46, 82.1%; 100% R0 resection). Patients with resected polyps presented non-advanced adenoma (n = 21, 45.6%) or advanced lesions (n = 25, 54.4%). There were no differences in erroneous orders with PoliCare CDSS (Kappa value 1.0).ConclusionsPoliCare CDSS can easily be integrated into the workflow for improving the overall efficiency and better adherence to evidence-based guidelines.     

Hyoscine N-butylbromide for adenoma detection during colonoscopy: A randomized,double-blind,placebo-controlled study

BackgroundHyoscine N-butylbromide (HBB), commonly used during colonoscopy to facilitate cecal intubation, has been proposed to increase the adenoma detection rate (ADR).AimsTo evaluate whether HBB administration increases the adenoma detection rate and influences patients’ tolerance.MethodsConsecutive colonoscopy outpatients were randomized after cecal intubation to receive either 20 mg HBB or placebo i.v. The number, size, histology and location of polyps were recorded. The air retained in the abdomen was either indirectly estimated by ΔAC (difference in the abdominal circumference measured before and after colonoscopy) or directly evaluated by patients’ perception (visual analogic scale, range 0–100).Results402 patients (44% male; mean age 57.7 ± 12.5 years) received either HBB or placebo. No differences in ADR (31.7% vs. 28%, p = 0.48), advanced-ADR (7.4% vs. 10.5%, p = 0.35) were observed between HBB and placebo group, respectively. A significantly lower detection rate of flat/depressed lesions was observed in the HBB group (0.5% vs. 5.5%, p = 0.003). The ΔAC and the bloating perception were comparable between the two groups (p = 0.22 and p = 0.48, respectively).ConclusionsHBB administered before colonoscope withdrawal does not increase adenoma detection rate and seems to hamper the visualization of flat/depressed lesions. This finding raises concerns on the indiscriminate use of HBB during colonoscopy.     

Narrow band imaging facilitates detection of inlet patches in the cervical oesophagus

BackgroundProximal esophageal heterotopic gastric mucosa or so-called inlet patch in the cervical oesophagus is easily missed on endoscopic examination because of its localisation, usually just below the upper oesophageal sphincter. We evaluated the clinical use of narrow band imaging for detection of inlet patches.MethodsIn this prospective, controlled observational study, 1407 subsequent patients underwent oesophagogastroduodenoscopy with or without narrow band imaging on withdrawal of the endoscope in the cervical oesophagus.ResultsOne endoscopist who was not aware of the prospective observation documented 6 (1.17%) cases of inlet patches in 515 oesophagogastroduodenoscopies compared to 4 cases out of 382 (1.05%) performed by the endoscopist who paid special attention to the presence of inlet patches but did not routinely apply narrow band imaging (OR 0.89, CI 95% 0.25–3.20, p = 0.85). In comparison, 17 cases of inlet patches out of 510 (3.33%) were detected by the endoscopist who routinely applied narrow band imaging. The detection rate of proximal oesophageal heterotopic gastric mucosa using narrow band imaging was significantly higher compared to white light endoscopy only (OR 3.06, CI 95% 1.39–6.73, p = 0.005).ConclusionsWithdrawal of the endoscope from the cervical oesophagus using narrow band imaging increased the detection of inlet patches about three-fold compared to standard white light endoscopy.     

El desafío de cuantificar la calidad de la colonoscopia de tamizaje: el desarrollo y las propiedades psicométricas de la Escala de Calidad en Colonoscopia

Introduction and aimsColonoscopy quality is measured by the degree in which the examination increases the likelihood of obtaining adequate results on health. Our aim was to develop an instrument for evaluating the quality of screening colonoscopies, taking into account the performance of endoscopists and endoscopy units.Materials and methodsMixed methodology was employed. The first stage (qualitative) consisted of a Medline search, from which a group of experts developed the quality score items. The second stage (quantitative) utilized a modified Delphi technique to reach consensus (3 rounds). We evaluated the psychometric properties of the instrument (reliability and construct validity) in elective screening colonoscopies (in patients ≥ 50 years of age), performed within the January-April 2017 time frame.ResultsA final instrument with 8 items was produced: 1) the Boston Bowel Preparation Scale score; 2) cecal intubation rate; 3) colonoscopy withdrawal time; 4) image documentation; 5) adenoma detection rate; 6) endoscopic surveillance planning; 7) perforation rate, and 8) continuous improvement programs. The instrument was evaluated in 323 colonoscopies performed by 31 endoscopists and found to be one-dimensional and reliable (Cronbach's alpha 0.76). Performance was compared between endoscopists (center 1) and an expert endoscopist from another center (center 2): Boston Bowel Preparation Scale score 8.3 vs. 7.36 (P < .001), cecal intubation rate 93.5 vs. 96%, colonoscopy withdrawal time 14.8 vs. 8.4 min (P < .001), and adenoma detection rate 34 vs. 52.2% (P < .001), respectively.ConclusionThe Colonoscopy Quality Score is a reliable and valid instrument for evaluating screening colonoscopy quality. Its results could be adapted to the usual endoscopic report to adjust monitorization frequency post-colonoscopy.     

High-definition with i-Scan gives comparable accuracy for detecting colonic lesions by non-expert and expert endoscopists

BackgroundLesion detection rate during colonoscopy may be influenced by the endoscopist's experience. EPK-i system colonoscopy (i-Scan) can improve mucosal and vascular visualization for detecting lesions.AimTo compare mucosal lesions detection rate and the withdrawal time of the instrument among non-expert and expert endoscopists.MethodsColonoscopy records of all consecutive patients undergoing first HD+ with i-Scan- or SWL-equipped colonoscopy for colorectal cancer screening over a twelve-month period were evaluated, in a “post hoc” analysis.Results542 colonoscopies (389 HD+ with i-Scan; 153 SWL): expert and non-expert endoscopists did respectively 272 and 117 HD+ with i-Scan and 83 and 70 SWL colonoscopies. Expert endoscopists did more i-Scan colonoscopies than non-experts (p = 0.006). In the SWL procedures, the experts detected mucosal lesions in more colonoscopies than non-experts (61/22 vs. 23/47, p = 0.0001) and found a significantly higher mean number of lesions (1.34 vs. 0.47; p = 0.0001). Experts detected more or less the same mean number of lesions with both imaging techniques, while among non-experts detection with HD+ with i-Scan was significantly better than with SWL imaging (1.39 vs. 0.47; p = 0.0001).ConclusionsHD+ with i-Scan imaging enables less skilled endoscopists to achieve results comparable to those of experienced ones in detecting mucosal lesions.     

Rural–urban differences in the long-term risk of colorectal cancer after adenoma removal: A population-based study

BackgroundWe investigated the impact of municipality of residence on colonoscopic surveillance and colorectal cancer risk after adenoma resection in a French well-defined administrative area.MethodsThis registry-based study included all patients residing in Côte d’Or (n = 5769) first diagnosed with colorectal adenomas between January 1, 1990, and December 31, 1999. Information about colonoscopic surveillance and colorectal cancer incidence was collected until December 31, 2003.ResultsA rural place of residence reduced the probability of colonoscopic surveillance in men [HR = 0.89 (95%CI: 0.79–0.99), p = 0.041] and in patients without family history of colorectal cancer [HR = 0.91(0.82–0.99), p = 0.044]. After a median follow-up of 7.7 years, 87 patients developed invasive colorectal cancer. After advanced adenoma removal, the standardized incidence ratio for colorectal cancer was 3.03 (95%CI: 1.92–4.54) for rural patients and 1.87 (95%CI: 1.26–2.66) for urban patients compared with the general population. The risk of colorectal cancer was higher in rural patients than in urban ones only after removal of the initial advanced adenoma [HR = 1.73 (95%CI: 1.01–3.00, p = 0.048)]. Further adjustment for surveillance colonoscopy, physician location, and other confounders had little impact on these results.ConclusionThe increased risk of subsequent colorectal cancer after advanced adenoma removal in French rural patients was not explained by a lower rate of colonoscopic surveillance. The role of socio-economic and environmental factors requires further exploration.     

Clinical impact of colonoscopy for patients with early gastric cancer treated by endoscopic submucosal dissection: A matched case–control study

BackgroundGastric cancer frequently occurs synchronously with colorectal cancer (CRC).AimsThe aim of the present study was to assess the value of colonoscopy in patients with primariy early gastric cancer (EGC) indicated for endoscopic submucosal dissection (ESD) and to identify predictors for the risk of high-risk adenomas.MethodsA total of 130 patients with EGC, who underwent both colonoscopy and gastric ESD, and 260 controls matched for age and sex, who underwent a colonoscopy as part of our institutional health check-up program.The prevalence of high-risk adenomas in EGC patients vs. controls was evaluated.ResultsHigh-risk adenomas were found in 43 (33%) EGC patients and 37 (14%) controls (P < 0.01). Multivariate analysis showed the presence of EGC was significantly associated with high-risk adenoma [odds ratio (OR) 2.8, 95% confidence interval (CI): 1.7–4.9]. Among EGC patients, high serum CEA level (OR 2.4, 95% CI: 1.2–5.0) was an independent predictor for high-risk adenoma.ConclusionsPatients with EGC had a significant risk for colorectal cancer. When endoscopists detected an early gastric cancer indicated for ESD, colonoscopy should be considered for EGC patients with high serum CEA levels.     

Risk of colorectal neoplasia in patients with celiac disease: A multicenter study

Background and aimsThe association of celiac disease with colorectal neoplasia is controversial. The aim of this study was to determine the risk of colorectal neoplasia among patients with celiac disease.MethodsWe carried out a multicenter, retrospective case–control study, within four community hospitals. Celiac disease patients with a complete colonoscopy were regarded as cases and those without celiac disease as controls. For each case, two controls matched for age, sex, indication for colonoscopy and colorectal cancer family history, were randomly selected. The main outcome evaluated was risk of colorectal polyps, adenomas, advanced neoplastic lesions and cancer.ResultsWe identified 118 patients with celiac disease and 236 controls. The risk of polyps, adenomas and advanced neoplastic lesions was similar in both groups (OR 1.25, CI 0.71–2.18, p = 0.40; OR 1.39, CI 0.73–2.63, p = 0.31; and OR 1.00, CI 0.26–3.72, p = 1.00, respectively). On multivariate analysis, age > 75 years old, and first-grade CRC family history were associated with adenomas (OR 2.68 CI 1.03–6.98, OR 6.68 CI 1.03–47.98 respectively) and advanced neoplastic lesions (OR 15.03, CI 2.88–78.3; OR 6.46 CI 1.23–33.79, respectively). With respect to celiac disease characteristic, a low adherence to a gluten free diet was independently associated with the presence of adenomas (OR 6.78 CI 1.39–33.20 p = 0.01).ConclusionsCeliac disease was not associated with an increased risk of colorectal neoplasia. Nonadherence to a strict gluten free diet was associated with the presence of adenomas. Further studies addressing celiac disease characteristics are needed to confirm this observation.     

Participation in colorectal cancer screening with FOBT and colonoscopy: An Italian,multicentre, randomized population study

BackgroundData on the adherence rate to screening colonoscopy (OC) in the average-risk general population are limited and variable. Aim of this study was to compare the uptake of OC screening with that of fecal occult blood (FOBT).MethodsA nationwide, population-based, multicentre, randomized trial comparing attendance to OC with that to FOBT was performed. Sixty-four general practitioners (GPs), overall including in their lists 9889 average-risk subjects aged 55–64 years, were randomized between OC and FOBT screening programs. Eligible subjects were mailed a personal invitation letter co-signed by their GP and the coordinator of the area-reference GI centre. Attendance rate and detection rate for advanced neoplasia (colorectal cancer, adenoma >10 mm or with villous histology or high-grade dysplasia) for each arm of the study were assessed.ResultsThe overall attendance rate was 18.7% (1563/8378 eligible subjects). It was markedly lower in the OC than in the FOBT strategy (10% vs. 27.1%; OR 0.28, 95% CI: 0.25–0.32; P < 0.0001). In particular, participation in OC screening arm was extremely low in South Italy (2.8%), whilst it was higher in North-Central Italy (12.4%; P < 0.0001). Compliance to colonoscopy in those with a positive FOBT was only 58%. Advanced neoplasia was detected in 28 (6.8%) patients in the OC arm and in 6 (18%) in those with a positive FOBT submitted to OC.ConclusionsThe results of our study underline the difficulties and barriers to implement a OC population screening in Italy, at least through primary care. Although attendance to FOBT was higher, it was disappointingly less than 30%. Significant actions to improve awareness amongst GPs and the population are a high priority.     

Experimental assessment of a novel robotically-driven endoscopic capsule compared to traditional colonoscopy

BackgroundDespite colonoscopy represents the conventional diagnostic tool for colorectal pathology, its undeniable discomfort reduces compliance to screening programmes.AimsTo evaluate feasibility and accuracy of a novel robotically-driven magnetic capsule for colonoscopy as compared to the traditional technique.MethodsEleven experts and eleven trainees performed complete colonoscopy by robotic magnetic capsule and by conventional colonoscope in a phantom ex vivo model (artificially clean swine bowel). Feasibility, overall accuracy to detect installed pins, procedure elapsed time and intuitiveness were measured for both techniques in both operator groups.ResultsComplete colonoscopy was feasible in all cases with both techniques. Overall 544/672 pins (80.9%) were detected by experimental capsule procedure, while 591/689 pins (85.8%) were detected within conventional colonoscopy procedure (P = ns), thus establishing non-inferiority. With the experimental capsule procedure, experts detected 74.2% of pins vs. 87.6% detected by trainees (P < 0.0001). Overall time to complete colon inspection by robotic capsule was significantly higher than by conventional colonoscopy (556 ± 188 s vs. 194 ± 158 s, respectively; P = 0.0001).ConclusionWith the limitations represented by an ex vivo setting (artificially clean swine bowel and the absence of peristalsis), colonoscopy by this novel robotically-driven capsule resulted feasible and showed adequate accuracy compared to conventional colonoscopy.     

A combination of clinical risk stratification and fecal immunochemical test is useful for identifying persons with high priority of early colonoscopy

BackgroundWe aimed to develop a combination screening strategy for advanced colorectal neoplasia based on the Asia-Pacific Colorectal Screening score and fecal immunochemical test results.MethodsWe reviewed the records of participants who had undergone a colonoscopy and fecal immunochemical test as part of a comprehensive health screening program. The prevalence of advanced colorectal neoplasia in participants 40–49 years old was analyzed according to Asia-Pacific Colorectal Screening scores and fecal immunochemical test results.ResultsWe analyzed the data of 9205 participants 40–49 years old and 3215 participants ≥50 years old. The prevalence of advanced colorectal neoplasia in participants 40–49 years old was 1.0%, 2.1%, 7.1%, and 13.4% in the “fecal immunochemical test (−) & Asia-Pacific Colorectal Screening < 2,” “fecal immunochemical test (−) & Asia-Pacific Colorectal Screening ≥ 2,” “fecal immunochemical test (+) & Asia-Pacific Colorectal Screening < 2,” and “fecal immunochemical test (+) & Asia-Pacific Colorectal Screening ≥ 2” subgroups, respectively. The prevalence of advanced colorectal neoplasia in “fecal immunochemical test (+) & Asia-Pacific Colorectal Screening ≥ 2” subgroup was higher than in participants ≥50 years old with Asia-Pacific Colorectal Screening ≥ 4 (13.4% vs. 5.8%, P < 0.001).ConclusionsFecal immunochemical test-positive individuals 40–49 years old with an Asia-Pacific Colorectal Screening ≥ 2 have a higher risk of advanced colorectal neoplasia than individuals ≥50 years old with an Asia-Pacific Colorectal Screening ≥ 4.     

Two dosages of remifentanil for patient-controlled analgesia vs. meperidine during colonoscopy: A prospective randomized controlled trial

Background and studyCombined use of opiates and benzodiazepines often results in delayed discharge after colonoscopy.AimsTo compare sedation quality of two dosages of patient controlled analgesia remifentanil with one another and with that of a midazolam-meperidine association during colonoscopy.MethodsNinety patients undergoing colonoscopy were randomly assigned to three groups. Group M received a meperidine bolus (0.7 mg/kg) and sham patient controlled analgesia. Group R1 received remifentanil 0.5 μg/kg and group R2 remifentanil 0.8 μg/kg together with a patient-controlled analgesia pump injecting further boluses (2-min lock-out). Technical difficulties of the examination, gastroenterologist's and patient's satisfaction with sedoanalgesia were evaluated after colonoscopy on a 100 mm Visual Analogue Scale. Patient's satisfaction was assessed 24 h later.ResultsGroup M had more adverse events (p = 0.044), required more rescue boluses (p = 0.0010), had lower Observer's Assessment of Alertness and Sedation Scale score at the end of the procedure (p = 0.0016) and longer discharge time (p = 0.0001). Groups R1 and R2 did not differ with respect to these variables. Patient's degree of pain and satisfaction with sedo-analgesia, endoscopist's technical difficulty and satisfaction were not different among groups.ConclusionsRemifentanil patient controlled analgesia is a safe approach to sedation for colonoscopy.     

The metabolic syndrome in early pregnancy and risk of gestational diabetes mellitus

AimThe objective of the present study was to determine whether or not maternal metabolic syndrome in early pregnancy in women without previous diabetes is associated with the development of gestational diabetes mellitus (GDM).MethodsA total of 508 women from the Rhea study—involving a pregnant cohort in Crete, Greece (2007–2009)—with singleton pregnancies were included in the present analysis. Maternal fasting serum samples were collected and blood pressure measured before gestational week 15. The metabolic syndrome in early pregnancy was defined according to NHLBI/AHA criteria. Pregnant women were screened for GDM between weeks 24 and 28 of gestation, as defined by Carpenter and Coustan criteria. Multivariable log-binomial regression models were used to estimate the effect of the metabolic syndrome in early pregnancy on the risk of GDM, after adjusting for confounding factors.ResultsWomen with the metabolic syndrome were at high risk of GDM (RR = 3.17; 95% CI: 1.06–9.50). Among the components of the metabolic syndrome, the most significant risk factors were impaired fasting glucose (RR = 4.92; 95% CI: 1.41–17.23) and pre-pregnancy obesity (RR = 2.65; 95% CI: 1.23–5.70). A 10-mmHg rise in systolic and diastolic blood pressure increased the relative risk of GDM by 49% (RR = 1.49; 95% CI: 1.10–2.02) and 34% (RR = 1.34; 95% CI: 1.04–1.73), respectively, whereas a 1-unit increase in pre-pregnancy BMI increased the relative risk of GDM by 6% (RR = 1.06; 95% CI: 1.01–1.12).ConclusionThese findings suggest that women with the metabolic syndrome in early pregnancy have a greater risk of developing GDM.     

Risk of cancer in small and diminutive colorectal polyps

The prevalence of cancer in small and diminutive polyps is relevant to “resect and discard” and CT colonography reporting recommendations.We evaluated a prospectively collected colonoscopy polyp database to identify polyps <10 mm and those with cancer or advanced histology (high-grade dysplasia or villous elements).Of 32,790 colonoscopies, 15,558 colonoscopies detected 42,630 polyps <10 mm in size. A total of 4790 lesions were excluded as they were not conventional adenomas or serrated class lesions.There were 23,524 conventional adenomas <10 mm of which 22,952 were tubular adenomas. There were 14,316 serrated class lesions of which 13,589 were hyperplastic polyps and the remainder were sessile serrated polyps. Of all conventional adenomas, 96 had high-grade dysplasia including 0.3% of adenomas ≤5 mm in size and 0.8% of adenomas 6–9 mm in size. Of all conventional adenomas, 2.1% of those ≤5 mm in size and 5.6% of those 6–9 mm in size were advanced. Among 36,107 polyps ≤5 mm in size and 6523 polyps 6–9 mm in size, there were no cancers.These results support the safety of resect and discard as well as current CT colonography reporting recommendations for small and diminutive polyps.