Adolfo Parra-Blanco

Colorectal endoscopic submucosal dissection: Is it suitable in western countries?

Endoscopic submucosal dissection (ESD) represents a significant advance in therapeutic endoscopy with the major advantage being the ability to achieve a higher en bloc resection rate for early stage lesions. Western endoscopists infrequently perform colorectal ESD (CR‐ESD) because of the greater technical difficulty involved, longer procedure times, and increased risk of perforation. Specialized training and sufficient clinical experience are necessary to successfully perform ESDs, but a systematic education and training program has still not been established in Japan or elsewhere in the world. Experts generally acknowledge that the stomach is the first organ in which endoscopists should begin performing ESDs. The incidence and detection rates for early stage gastric cancer are significantly higher in Japan than in western countries, so Japanese endoscopists have a greater opportunity to perform gastric ESDs than their western counterparts. It is logical to ask, therefore, whether CR‐ESD can be effectively applied in western countries. Based on a review of the relevant literature and our practical perspective, we have focused on the progress made in performing CR‐ESD, its indications, training methods, and learning curve. Use of animal gastric and colon models is strongly recommended along with accumulating the necessary experience from the rectum to the colon on a step‐by‐step basis. It is reasonable to assume that an increasing number of CR‐ESDs will be performed by western endoscopists in the foreseeable future given the continuing development of new techniques, and the refinement of instruments and other technologically advanced devices together with the creation of even more effective submucosal injection agents.

Predictive factors for initial treatment response after circumferential radiofrequency ablation for Barrett's esophagus with early neoplasia: a prospective multicenter study.

BACKGROUND AND STUDY AIMSnRadiofrequency ablation (RFA) is safe and effective for the eradication of neoplastic Barretts esophagus; however, occasionally there is minimal regression after initial circumferential balloon-based RFA (c-RFA). This study aimed to identify predictive factors for a poor response 3 months after c-RFA, and to relate the percentage regression at 3 months to the final treatment outcome.nnnMETHODSnWe included consecutive patients from 14 centers who underwent c-RFA for high grade dysplasia at worst. Patient and treatment characteristics were registered prospectively. Poor initial response was defined as < 50 % regression of the Barretts esophagus 3 months after c-RFA, graded by two expert endoscopists using endoscopic images. Predictors of initial response were identified through logistic regression analysis.nnnRESULTSnThere were 278 patients included (median Barretts segment C4M6). In poor initial responders (n = 36; 13 %), complete response for neoplasia (CR-neoplasia) was ultimately achieved in 86 % (vs. 98 % in good responders; P < 0.01) and complete response for intestinal metaplasia (CR-IM) in 66 % (vs. 95 %; P < 0.01). Poor responders required 13 months treatment (vs. 7 months; P < 0.01) for a median of four RFA sessions (vs. three; P < 0.01). We identified four independent baseline predictors of poor response: active reflux esophagitis (odds ratio [OR] 37.4; 95 % confidence interval [CI] 3.2 - 433.2); endoscopic resection scar regeneration with Barretts epithelium (OR 4.7; 95 %CI 1.1 - 20.0); esophageal narrowing pre-RFA (OR 3.9; 95 %CI 1.0 - 15.1); and years of neoplasia pre-RFA (OR 1.2; 95 %CI 1.0 - 1.4).nnnCONCLUSIONSnPatients with a poor initial response to c-RFA have a lower ultimate success rate for CR-neoplasia/CR-IM, require more treatment sessions, and a longer treatment period. A poor initial response to c-RFA occurs more frequently in patients who regenerate their endoscopic resection scar with Barretts epithelium, and those with ongoing reflux esophagitis, neoplasia in Barretts esophagus for a longer time, or a narrow esophagus.

Investigating endoscopic features of sessile serrated adenomas/polyps by using narrow-band imaging with optical magnification

BACKGROUNDnA sessile serrated adenoma/polyp (SSA/P) is a common type of colorectal polyp that possesses malignant potential. Although narrow-band imaging (NBI) can easily differentiate neoplastic lesions from hyperplastic polyps (HPs), SSA/Ps can be a challenge to distinguish from HPs.nnnOBJECTIVEnTo investigate specific endoscopic features of SSA/Ps by using NBI with optical magnification.nnnDESIGNnRetrospective study.nnnSETTINGnSingle high-volume referral center.nnnPATIENTSnA total of 289 patients with histopathologically proven SSA/Ps or HPs obtained from colonoscopic polypectomy.nnnINTERVENTIONnEndoscopic images obtained by using NBI with optical magnification of 242 lesions (124 HPs, 118xa0SSA/Ps) removed between January 2010 and December 2012 were independently evaluated by 2 experienced endoscopists. Three external experienced endoscopists systematically validated the diagnostic accuracies by using 40 lesions (21 HPs and 19 SSA/Ps) removed between January and Marchxa02013.nnnMAIN OUTCOME MEASUREMENTSnSpecific endoscopic features of SSA/Ps by using 5 potential characteristics: dilated and branching vessels (DBVs), irregular dark spots, a regular network pattern, a disorganized network pattern, and a dense pattern.nnnRESULTSnMultivariate analysis demonstrated that DBV had a 2.3-fold odds ratio (95% confidence interval, 0.96-5.69) among SSA/Ps compared with HPs (sensitivity, 56%; specificity, 75%; accuracy, 65%). Interobserver and intraobserver agreement indicated almost perfect agreement for DBVs in both the evaluation and validation studies. When DBVs, proximal location, and tumor size (≥10xa0mm) were combined, the positive predictive value was 92% and the area under the curve was 0.783 in the receiver-operating characteristics by using the validation group.nnnLIMITATIONSnRetrospective study.nnnCONCLUSIONSnThe current study suggests that a DBV is a potentially unique endoscopic feature of a colorectal SSA/P.

Animal models for endoscopic training: do we really need them?

Gastrointestinal endoscopy currently includes many therapeutic methods that are technically challenging and frequently associated with a significant risk of complications. Several issues such as the limited number of clinical cases and practice in emergency situations, and technical difficulty may limit the opportunity for training, and increased exposure in more relaxed situations would be desirable. Moreover, providing the patient with the best possible standard of care is a must. Animal models are the most easily available simulators. Training in these models has been recommended for several complex techniques, among which hemostasis, endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, and endoscopic submucosal dissection are reviewed here. Ex vivo models are much easier to set up and, from an ethical standpoint, they should be used for the initial step in training whenever possible before moving on to in vivo models. Although simulation with animal models has been the subject of a good number of studies, very few of them have evaluated the impact on clinical outcomes, and clearly more studies are needed. Nevertheless, available evidence does suggest that practicing on animal models has an influence on the learning curve and facilitates the acquisition of skills in the complex endoscopic techniques reviewed.

Endoscopic predictors of deep submucosal invasion in colorectal laterally spreading tumors.

BACKGROUND AND STUDY AIMSnThe depth of invasion of the bowel wall influences the treatment of colorectal laterally spreading tumors (LSTs). The aim of this study was to evaluate the risk factors and patterns of submucosal invasion in a large series of LSTs that were removed en bloc.nnnPATIENTS AND METHODSnProspectively collected endoscopic and pathological data on a total of 822 LSTs, ≥u200a10u200amm in size and removed en block by endoscopic submucosal dissection (nu200a=u200a670) or surgery (nu200a=u200a152), were retrospectively analyzed.nnnRESULTSnIn 414 LSTs of the granular type, submucosal invasion was detected in 80 cases (19u200a%; 95u200a% confidence interval [CI] 16u200a-u200a23) and was deep (≥xa01000u200aμm) in 79u200a% of cases. The invasion site was under a large (≥u200a10u200amm) nodule (56u200a%), depression (28u200a%), or was multifocal (16u200a%). Risk factors for deep submucosal invasion on multivariate analysis were the presence of a large nodule (odds ratio [OR] 12, 95u200a%CI 2u200a-u200a59), depression (OR 59, 95u200a%CI 9u200a-u200a387), and invasive pit pattern (OR 33, 95u200a%CI 12u200a-u200a88). The sensitivity and specificity of invasive pit pattern for detection of deep submucosal invasion were 52u200a% (95u200a%CI 40u200a%u200a-u200a64u200a%) and 98u200a% (95u200a%CI 96u200a%u200a-u200a99u200a%), respectively.In 408 LSTs of the nongranular type, submucosal invasion was detected in 159 cases (39u200a%; 95u200a%CI 34u200a-u200a44) and was deep in 54u200a% of cases. The invasion site was under a submucosal mass-like elevation (10u200a%), depression (45u200a%), or was multifocal (45u200a%). Risk factors for deep submucosal invasion were the presence of a submucosal mass-like elevation (OR 8, 95u200a%CI 1u200a-u200a61), depression (OR 28, 95xa0%CI 8u200a-u200a97), and invasive pit pattern (OR 79, 95xa0%CI 25u200a-u200a256).nnnCONCLUSIONSnBecause of a substantial risk of submucosal invasion and multifocal invasion, granular type LSTs with a large nodule or depression and nongranular type LSTs should be endoscopically removed en bloc.

Endoscopic submucosal dissection.

Endoscopic submucosal dissection (ESD) enables en bloc resection of certain types of early gastrointestinal neoplasias with the help of different knives, of which the insulated-tip, or IT, knife is the most frequently used. The IT knife is a variant of the needle knife, tipped with a ceramic ball to prevent cutting through muscularis propria. ESD is applied throughout the gastrointestinal tract, mostly in the stomach and colon. Although widely used in Japan, reports on ESD from western countries are infrequent. A total of six cases of ESD from two Czech gastroenterology centers are presented here.

Development of an E-learning System for the Endoscopic Diagnosis of Early Gastric Cancer: An International Multicenter Randomized Controlled Trial

Background In many countries, gastric cancer is not diagnosed until an advanced stage. An Internet-based e-learning system to improve the ability of endoscopists to diagnose gastric cancer at an early stage was developed and was evaluated for its effectiveness. Methods The study was designed as a randomized controlled trial. After receiving a pre-test, participants were randomly allocated to either an e-learning or non-e-learning group. Only those in the e-learning group gained access to the e-learning system. Two months after the pre-test, both groups received a post-test. The primary endpoint was the difference between the two groups regarding the rate of improvement of their test results. Findings 515 endoscopists from 35 countries were assessed for eligibility, and 332 were enrolled in the study, with 166 allocated to each group. Of these, 151 participants in the e-learning group and 144 in the non-e-learning group were included in the analysis. The mean improvement rate (standard deviation) in the e-learning and non-e-learning groups was 1·24 (0·26) and 1·00 (0·16), respectively (P < 0·001). Interpretation This global study clearly demonstrated the efficacy of an e-learning system to expand knowledge and provide invaluable experience regarding the endoscopic detection of early gastric cancer (R000012039).

A randomized trial to compare the efficacy and tolerability of sodium picosulfate-magnesium citrate solution vs. 4 L polyethylene glycol solution as a bowel preparation for colonoscopy

PurposeThe purpose of this study is to compare the efficacy and acceptability of an evening-before regimens of sodium picosulfate/magnesium citrate (SPMC) and polyethylene glycol (PEG) as bowel cleansers and to explore the results of a same-day regimen of SPMC.MethodsMulticenter, randomized, observer-blinded, parallel study carried out in subjects who were 18–80xa0years old and were undergoing diagnostic colonoscopy for the first time. The primary outcome was treatment success, which was a composite outcome defined by (1) the evaluation of the overall preparation quality as “excellent” or “good” by two blinded independent evaluators with the Fleet® Grading Scale for Bowel Cleansing and (2) a subject’s acceptability rating of “easy to take” or “tolerable.” The primary outcome was analyzed using a logistic regression with site, gender, and age group (age ≥65xa0years and <65xa0years) as factors.ResultsFour hundred ninety subjects were included in the efficacy evaluation. Although treatment success was significantly higher in subjects assigned to the evening-before regimen of SPMC vs. subjects assigned to the evening-before PEG, when evaluating the two individual components for treatment success, there were significant differences in the ease of completion but not in the quality of preparation. The same-day SPMC regimen was superior to both the evening-before regimen of SPMC and PEG in terms of the quality of preparation, especially regarding the proximal colon.ConclusionsAn evening-before regimen of SPMC is superior to an evening-before regimen of PEG in terms of subject’s acceptability. The same-day SPMC regimen provides better cleansing levels in the proximal colon.

Diagnóstico precoz de cáncer gástrico: Propuesta de detección y seguimiento de lesiones premalignas gástricas: protocolo ACHED

An expert panel analyzed the available evidence and reached a consensus to release 24 recommendations for primary and secondary prevention of gastric cancer (CG) in symptomatic patients, with indication for upper GI endoscopy. The main recommendations include (1) Search for and eradicate H. pylori infection in all cases. (2) Systematic gastric biopsies (Sydney protocol) in all patients over 40 years of age or first grade relatives of patient with CG, to detect gastric atrophy, intestinal metaplasia or dysplasia. (3) Incorporate the OLGA system (Operative Link on Gastritis Assessment) to the pathological report, to categorize the individual risk of CG. (4) Schedule endoscopic follow-up according to the estimated risk of CG, namely annual for OLGA III- IV, every 3 years for OLGA I- II or persistent H. pylori infection, every 5 years for CG relatives without other risk factors and no follow-up for OLGA 0, H. pylori (-). (4) Establish basic human and material resources for endoscopic follow-up programs, including some essential administrative processes, and (5) Suggest the early CG/total CG diagnosis ratio of each institution and the proportion of systematic recording of endoscopic images, as quality indicators. These measures are applicable using currently available resources, they can complement any future screening programs for asymptomatic population and may contribute to improve the prognosis of CG in high-risk populations.

Endoscopic submucosal dissection: Sociedad Española de Endoscopia Digestiva (SEED) clinical guideline

Gloria Fernandez-Esparrach, Angel Calderon, Joaquin de-la-Pena, Jose B. Diaz-Tasende, Jose Miguel Esteban, Antonio Zebenzuy Gimeno-Garcia, Alberto Herreros-de-Tejada, David Martinez-Ares, David Nicolas-Perez, Oscar Nogales, Akiko Ono, Aitor Orive-Calzada, Adolfo Parra-Blanco, Sarbelio Rodriguez-Munoz, Eloy Sanchez-Hernandez, Andres Sanchez-Yague, Enrique Vazquez-Sequeiros, Juan Vila and Leopoldo Lopez-Roses; on behalf of the Sociedad Espanola de Endoscopia Digestiva (SEED)