Endoscopic innovations to increase the adenoma detection rate during colonoscopy

Up to a quarter of polyps and adenomas are missed during colonoscopy due to poor visualization behind folds and the inner curves of flexures, and the presence of flat lesions that are difficult to detect. These numbers may however be conservative because they mainly come from back-to-back studies performed with standard colonoscopes, which are unable to visualize the entire mucosal surface. In the past several years, new endoscopic techniques have been introduced to improve the detection of polyps and adenomas. The introduction of high definition colonoscopes and visual image enhancement technologies have been suggested to lead to better recognition of flat and small lesions, but the absolute increase in diagnostic yield seems limited. Cap assisted colonoscopy and water-exchange colonoscopy are methods to facilitate cecal intubation and increase patients comfort, but show only a marginal or no benefit on polyp and adenoma detection. Retroflexion is routinely used in the rectum for the inspection of the dentate line, but withdrawal in retroflexion in the colon is in general not recommended due to the risk of perforation. In contrast, colonoscopy with the Third-Eye Retroscope^® may result in considerable lower miss rates compared to standard colonoscopy, but this technique is not practical in case of polypectomy and is more time consuming. The recently introduced Full Spectrum Endoscopy™ colonoscopes maintains the technical capabilities of standard colonoscopes and provides a much wider view of 330 degrees compared to the 170 degrees with standard colonoscopes. Remarkable lower adenoma miss rates with this new technique were recently demonstrated in the first randomized study. Nonetheless, more studies are required to determine the exact additional diagnostic yield in clinical practice. Optimizing the efficacy of colorectal cancer screening and surveillance requires high definition colonoscopes with improved virtual chromoendoscopy technology that visualize the whole colon mucosa while maintaining optimal washing, suction and therapeutic capabilities, and keeping the procedural time as low and patient discomfort as optimal as possible.     

Possible antistenotic effect of tranilast in a patient with small bowel tuberculosis to prevent intestinal obstruction due to stenosis progression by antituberculous chemotherapy

Small intestinal tuberculosis is a rare disorder of the small intestine. We report the development of deep small bowel tuberculosis in a rheumatoid arthritis patient who was taking methotrexate. The diagnosis of small bowel tuberculosis was ascertained by typical endoscopic findings and production of interferon gamma in the peripheral blood. The patient was successfully treated with antituberculous chemotherapy combined with an antifibrotic agent, tranilast, to suppress the progression of intestinal stenosis toward symptomatic stricture.     

A simple method to improve adenoma detection rate during colonoscopy: Altering patient position

BACKGROUND:

Colonoscopy is currently considered to be the gold standard method for detecting and removing adenomatous polyps. However, tandem colonoscopy studies reveal a pooled polyp miss rate of 22%.

OBJECTIVE:

A prospective randomized trial was conducted to assess whether alteration of patient position during colonoscopy withdrawal increases the adenoma detection rate (ADR).

METHOD:

The study group included 120 patients who presented for elective colonoscopic examination. After reaching the cecum, patients were randomly assigned in a 1:1 ratio to examination in either the left lateral position or other positions (left lateral position for the cecum, ascending colon and hepatic flexure; supine for transverse colon; and supine and right lateral position for splenic flexure, descending and sigmoid colon) first. Examination of the colon was performed segment by segment. The size, morphology and location of all polyps were recorded. Polyps were removed immediately after examination of a colon segment when all positions were completed. ADR and polyp detection rates (PDR) were calculated.

RESULTS:

A total of 102 patients completed the study. Examination in the left lateral position revealed 66 polyps in 31 patients (PDR 30.3%) and 42 adenomas in 24 patients (ADR 23.5%). PDR increased to 43.1% (81 polyps in 44 patients) and the ADR to 33.3% (53 adenomas in 34 patients) after the colon was examined in the additional positions (P<0.001 and P=0.002, respectively). The increase in the number of adenomas detected was statistically significant in the transverse and sigmoid colon. The addition of position changes led to a 9.8% increase in the ADR in the transverse colon, splenic flexure, and descending and sigmoid colon. The frequency of surveillance interval was shortened in nine (8.8%) patients after examination of the colon in dynamic positions.

CONCLUSION:

Alteration of patient position during colonoscopy withdrawal is a simple and effective method to improve ADR.     

No increased risk of perforation during colonoscopy in patients undergoing Nurse Administered Propofol Sedation

Abstract

Objective. Nurse Administered Propofol Sedation (NAPS) contributes to a deeper sedation of the patients, making them unable to respond to pain and an increased incidence of perforations has been speculated. The objective of this study was to evaluate the risk of perforations during colonoscopies performed with either NAPS or conventional sedation regimes. Material and methods. Data were retrospectively retracted from medical journals from 1 January 2007 to 31 December 2011. All journals were examined and cross-referenced to reveal any perforations. We analyzed all colonoscopies in regard to nature of the procedure (diagnostic vs therapeutic), experience of the endoscopist and ASA-classification of the patients. Results. A total of 6371 colonoscopies were performed, of which 3155 were performed under propofol sedation. There were 16 perforations (0.25%); 10 of these performed during NAPS and 6 during conventional colonoscopy (p = 0.454, OR: 1.7 (95% CI: 0.6–5.7)). There were 4874 diagnostic and 1497 therapeutic colonoscopies, with a majority of the perforations (94%) occurring during a diagnostic procedure (p = 0.389). No statistically difference was found in the incidence of perforations caused by an experienced or less experienced endoscopist (p = 0.589). Conclusion. The risk of colonic perforations during colonoscopy was not found to be significantly higher in patients undergoing NAPS compared to patients undergoing conventional sedation, although a tendency may exist. Furthermore, we found no correlation to neither experience of the endoscopist, nature of the procedure nor sex of the patients. Larger and prospective studies are needed to further evaluate on this subject.     

Review: ‘Case of the month’: a novel way to learn from endoscopy-related patient safety incidents

Patient safety incidents (PSIs) are unintended or unexpected incidents which can or do lead to patient harm. The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) acknowledges that PSIs should be reviewed by endoscopy services and learning shared among staff. It is recognised that more could be done to promote shared learning as outlined by the JAG ‘Improving Safety and Reducing Error in Endoscopy’ strategy. The ‘Case of the month’ series aims to provide a broad selection of cases and subsequent learning that can be shared among services and their workforce. This review focuses on five case vignettes that highlight a variety of PSIs in endoscopy. A structured approach, based on incident analysis methodology, is applied to each case to categorise PSIs and develop learning points. Learning is directed toward the individual, team and healthcare organisation. A selection of methods to disseminate learning at local, regional and national levels are also described.     

cFLIP expression correlates with tumour progression and patient outcome in non-Hodgkin lymphomas of low grade of malignancy

The present study investigated whether the expression of cellular Fas-associated death domain-like interleukin-1beta-converting enzyme (FLICE) inhibitory protein (cFLIP) conveys prognostic information in non-Hodgkin lymphomas (NHLs). cFLIP expression was quantified by immunohistochemistry and immunofluorescence in biopsy specimens from 86 NHL patients for whom clinical information was available. NHL malignancy was graded as high/intermediate or low according to the World Health Organization Classification of Lymphoid Neoplasms. cFLIP was positive in 23 of 45 high-/intermediate-grade NHLs and in 25 of 41 low-grade NHLs. Negative expression of cFLIP was associated with the presence of apoptotic cells in the tumour mass, regardless of the histotype and of the malignancy grade. In NHLs positive for cFLIP, 11 of 23 (48%) high-/intermediate-grade cases and 18 of 25 (72%) low-grade cases showed a bad outcome. In NHLs negative for cFLIP, only four of 22 (18%) high-/intermediate-grade patients and 12 of 16 (75%) low-grade patients achieved complete remission. All these correlations were statistically significant. The correlation of cFLIP expression with clinical outcome was independent of therapy, whether or not it included anti-CD20 antibody (Rituximab). The present findings strongly indicate that cFLIP is a reliable predictor of tumour progression and clinical prognosis in NHLs of low grade of malignancy.     

Pilot study to assess patient outcomes following endoscopic application of photodynamic therapy for advanced cholangiocarcinoma

BACKGROUND: Photodynamic therapy (PDT) has demonstrated promise in the palliative treatment of advanced cholangiocarcinoma. The aim of this pilot study was to assess the outcome in patients with non-resectable cholangiocarcinoma following endoscopic application of PDT directly into the biliary tract. METHODS: In patients with advanced cholangiocarcinoma, endoscopic retrograde cholangiopancreatography (ERCP) was performed to define the proximal and distal extent of intraductal tumor. Sodium porfimer was administered intravenously to all patients. Forty-eight hours later, a commercially available cylindrical diffusing laser fiber (1-2.5 cm in length, OptiGuide) designed for esophageal use was advanced across the biliary strictures. Laser light was applied at a power of 400 mW/cm fiber for a total energy of 180 J/cm(2) using an argon-pumped tunable dye laser. Patients received endoscopic PDT every 3 months provided they maintained a favorable performance status. Plastic biliary stents were replaced immediately following light application and were maintained in all patients. RESULTS: Using a preloaded catheter, adequate positioning of the laser fiber was achieved in all patients. Eight patients with advanced cholangiocarcinoma received a total of 19 PDT treatments, range 1-5 treatments/patient. All eight patients were followed until death; mean follow-up was 9.8 months. Median survival from the date of the first PDT treatment was 276 days, which compares favorably with published series that have reported median survival times between 45 and 127 days for patients with bismuth type III and IV tumors treated with stenting alone. CONCLUSIONS: Endoscopic application of PDT demonstrates promise in prolonging survival in patients with advanced cholangiocarcinoma. Additional randomized clinical trials using commercially available fibers are needed to fully evaluate both the optimum frequency and treatment interval of endoscopic PDT in the management of advanced cholangiocarcinoma.     

Biphasic rate of CD4+ cell count decline during progression to AIDS correlates with HIV-1 phenotype.

OBJECTIVE: To determine the kinetics of decline of CD4+ lymphocytes in HIV-1-infected asymptomatic homosexual men. METHODS: CD4+ lymphocytes were enumerated in a cohort of 187 HIV-1-infected initially asymptomatic homosexual men seen at 3-month intervals over 5 years. During follow-up, 45 men progressed to AIDS (excluding cases presenting with Kaposi's sarcoma). Correlation between rate of CD4+ cell decline and presence of a particular HIV-1 biological phenotype was analysed in 43 participants. RESULTS: CD4+ cell counts declined slowly and continuously in HIV-1-seropositive men who remained asymptomatic during follow-up. A biphasic CD4+ cell count decline was observed in the group who developed AIDS: the decline was slow and steady (5.6 x 10(6)/l per month, similar to that observed in the asymptomatic group) until 18 months before AIDS diagnosis, but became three to five times faster thereafter. Rapid CD4+ cell decline was significantly related to syncytium-inducing, fast-replicating HIV-1 isolates; during the period of slow and steady CD4+ cell count decline, non-syncytium-inducing isolates were predominant. CONCLUSIONS: At an average of 18 months preceding AIDS diagnosis, a three to fivefold increase in the rate of loss of CD4+ lymphocytes occurs, and may be related to the appearance of a more virulent HIV-1 phenotype.     

Patient factors predictive of pain and difficulty during sedation-free colonoscopy: A prospective study in Korea

BACKGROUND: Successful colonoscopy depends on insertion of the instrument to the cecum, precise observation, and minimal patient discomfort during the procedure. This prospective study was designed to identify factors, apart from the endoscopist's skill, that predict patient pain and technical difficulty during sedation-free colonoscopy. METHODS: A total of 426 sedation-free colonoscopies performed by one experienced endoscopist were evaluated in a prospective manner. Factors were recorded, including patient pain level, intubation time, demographic data, history of abdominal surgery, bowel preparation status, diverticular disease, bowel habits, anxiety level, and number of previous colonoscopies. These factors were analysed to determine their association with difficulty and pain during the procedure. RESULTS: Four hundred six colonoscopies were completed to the cecum (95.3%). Mean insertion time for complete colonoscopy was 6.5+/-3.5 min. Multivariate logistic regression analyses revealed that older age, lower body mass index, previous hysterectomy, diarrhoea, 1st time colonoscopy and anxiety were predictors of patient pain. Older age, lower body mass index and previous hysterectomy were predictors of difficulty of intubation. CONCLUSIONS: This prospective study identified several factors that may predict patient pain and technical difficulty associated with the procedure. These findings have implications for the practice and teaching of colonoscopy.     

Cumulative sum (Cusum) analysis provides an objective measure of competency during training in endoscopic retrograde cholangio-pancreatography (ERCP)

Background and Aim:

Endoscopic retrograde cholangio-pancreatography (ERCP) is a complex and technically challenging procedure with a risk of significant complications. Although recommendations exist as to how many ERCPs should be performed before a trainee is deemed competent they lack objective measures of outcome. Cumulative sum (Cusum) analysis allows continuous monitoring of a proceduralist''s performance to ensure acceptable outcomes are being achieved. The aim of the present study was to assess a trainee''s progress with ERCP using Cusum analysis.

Method:

A single trainee performed one supervised ERCP list per week between June 2005 and May 2008. Prospective data were collected and analysed by intention to treat using Cumulative failure charting and Cusum analysis. The binary outcome measure was successful cannulation in patients with a native sphincter. Acceptable and unacceptable cannulation failure rates were set at 20% and 35% respectively, with Type I and II error rates set at 0.10.

Results:

A total of 290 ERCPs were performed. Successful cannulation was achieved in 168 of 238 (70.6%) patients with intact biliary sphincters. Although cumulative failure charting suggested the trainee had not yet achieved satisfactory performance, Cusum analysis with sequential probability ratio testing indicated that an acceptable outcome had been achieved for the last 179 consecutive ERCPs.

Conclusion:

Cusum analysis enables sensitive and continuous monitoring of a trainee''s performance to objectively determine competency. Wider and systematic use may enable appropriate benchmarks to be identified and more objective assessment of a trainee''s experience.     

Using patient experience to measure the quality of HIV care

Measurement of health-care quality in the UK is no longer restricted to evaluating the effectiveness of treatments or the cost efficiency of services. There is a drive towards a patient-based agenda which enables them to make a clear contribution to the way services are shaped by expressing their values and sharing experiences. Positive engagement with HIV care has proven benefits to patients and the mandatory use of standardized reported outcome measures provides an opportunity to include HIV patients in the process of creating and refining an evaluation tool which places emphasis on aspects of care that are significant to them. Ultimately, this will provide services users with a stronger voice to guide appropriate service change and support the continuing improvement of HIV care.     

A randomized controlled trial of total colonic decompression after colonoscopy to improve patient comfort

OBJECTIVES: Bloating occurring after colonoscopy may cause significant discomfort in some patients. We sought to determine whether total colonic decompression decreased bloating and improved comfort after colonoscopy. METHODS: Consecutive outpatients undergoing elective colonoscopy were randomized to total colonic decompression or to the control group after completion of the routine colonoscopy. The colonoscope was advanced again to the cecum and the air aspirated during withdrawal in patients randomized to decompression and the procedure was terminated without decompression in control patients. Pain and bloating was assessed in the recovery room and in 24-48 h using a five-point scale. RESULTS: Sixty-five patients were randomized to decompression and 61 were randomized to the control group. The baseline demographic and procedural characteristics were similar between the two groups, but decompression took significantly longer (median, 17 min vs 14 min, p = 0.0002). Seventy-five percent of the decompression group and 80% of the control group denied any pain during colonoscopy. Significantly fewer patients from the decompression group complained of bloating after the procedure (25% vs 59%, p < 0.001) when questioned in the recovery room. However, comparable patients complained of postprocedure bloating when questioned in 24-48 h after the procedure (45% of decompression group vs 47% of control group, p = 0.86). The nurse and the endoscopist were poor at predicting the patient's bloating and significantly overestimated the level of pain. CONCLUSIONS: Total colonic decompression does not significantly reduce bloating after colonoscopy when assessed 24-48 h after the procedure.