Andreea Bengus

PillCam Colon 2 capsule in patients unable or unwilling to undergo colonoscopy

AIM To assess the feasibility, accuracy and acceptability of PillCam Colon 2 in detection of significant lesions in colorectal cancer risk patients, unable or unwilling to perform colonoscopy. METHODS This is a prospective, single center study using the second generation of PillCam Colon capsule. In all patients the readers were instructed to review the entire colon capsule endoscopy (CCE) examination using Rapid 7 software and additionally to note significant extra-colonic findings. Colonic significant findings were described according to European Society of Gastrointestinal Endoscopy guidelines. CCE procedure completion rate, level of bowel preparation and rate of adverse events were assessed. RESULTS A total of 70 patients at risk of colorectal cancer were enrolled in the study. In three patients the procedure failed because the capsule was not functioning when entered the colon. PillCam Colon 2 showed positive findings in 23 (34%, 95%CI: 21.6%-44.1%) of the remaining 67 patients. Six patients were diagnosed with tumors: 4 with colon cancers, 1 with gastric cancer and 1 with a small bowel cancer. The capsule findings were confirmed after surgery in all these patients. The capsule excretion rate in twelve hours was 77% with 54 patients having a complete examination. The rectum was not explored during CCE procedure, in 16 patients (23%, 95%CI: 13.7%-34.1%). Every patient accepted CCE as an alternative exploration tool and 65/70 (93%) agreed to have another future control by CCE. No complications were reported during or after CCE examination. CONCLUSION PillCam Colon 2 capsule was effective in detecting significant lesions and might be considered an adequate alternative diagnostic tool in patients unable or unwilling to undergo colonoscopy.

Trainee caseload correlates with ERCP success rates but not with procedure-related complications: results from a prospective study (the QUASIE cohort)

Background and study aim: Endoscopy society guidelines recommend a minimum of 200 cases for endoscopic retrograde cholangiopancreatography (ERCP) trainees in order to ensure competency and quality standards. However, there are few data regarding procedure-related complication rates and added risk for patients during this learning process. We aimed to evaluate the correlation between trainee caseload and procedure- and patient-related outcomes in an ERCP training program, and to assess the risk factors for ERCP failure and complications. Patients and methods: We conducted a prospective study of all procedures performed in the ERCP training program at Colentina Clinical Hospital, Bucharest, Romania. Relevant data for each procedure (diagnosis, cannulation method, outcome, and complications during the following 30 days) as well as operator experience were documented. Univariable and multivariable analysis of the risk factors for ERCP failure and complications was done by analyzing the procedures completed by expert and trainee endoscopists during the study period. Results: The analysis included 534 ERCPs performed by 1 expert and 3 supervised trainees during a 12-month period. Technical success rates were comparable in the trainee and expert groups, and no statistically significant difference was found between the two groups with regard to procedure-related complications and mortality. The more experienced trainees had a better chance of successfully completing a procedure (odds ratio of 1.1 for each additional 10 ERCPs performed), but post-ERCP complications were unrelated to individual trainee caseloads on multivariable analysis. Conclusion: The ERCP technical success rate increases with trainee experience, reflecting the learning curve of individual operators. However, the complication rates are similar across different levels of operator experience, indicating that ERCPs performed by supervised trainees imply no additional risk for patients.

Expression Profile of p53 and p21 in Large Bowel Mucosa as Biomarkers of Inflammatory-Related Carcinogenesis in Ulcerative Colitis

Ulcerative colitis (UC) is a chronic, relapsing inflammatory bowel disease that slightly increases the risk of colorectal cancer in patients with long-standing extended disease. Overexpression of p53 and p21 in colonic epithelia is usually detected in UC patients when no dysplasia is histologically seen and it is used by pathologists as a discriminator between regenerative changes and intraepithelial neoplasia, as well as a tissue biomarker useful to predict the risk of evolution toward malignancy. We present a one-year prospective observational study including a cohort of 45 patients with UC; p53 and p21 were evaluated in epithelial cells. p53 was positive in 74 samples revealed in 5% to 90% of epithelial cells, while 63 biopsies had strong positivity for p21 in 5% to 50% of epithelial cells. Architectural distortion was significantly correlated with p53 overexpression in epithelial cells. Thus, we consider that architectural distortion is a good substitute for p53 and p21 expression. We recommend use of p53 as the most valuable tissue biomarker in surveillance of UC patients, identifying the patients with higher risk for dysplasia. Association of p21 is also recommended for a better quantification of risk and for diminishing the false-negative results.

Is virtual chromoendoscopy useful in the evaluation of subtle ulcerative small-bowel lesions detected by video capsule endoscopy?

Background: The identification of subtle small-bowel mucosal lesions by video capsule endoscopy (VCE) can be challenging. Virtual chromoendoscopy techniques, based on narrowing the bandwidth of conventional white light endoscopic imaging (WLI), were developed to improve the analysis of mucosal patterns. However, data on the already-implemented Flexible spectral Imaging (or Fujinon Intelligent) Color Enhancement (FICE) software application in VCE are limited. Materials and methods: An evaluation of 250 difficult-to-interpret small-bowel ulcerative and 50 artifact lesions selected from 64 VCE recordings was conducted by four experienced VCE readers in two steps: initially as WLI, then with the addition of all available virtual chromoendoscopy pre-sets (FICE 1, 2, and 3 and Blue mode). The readers labeled them as real or false ulcerative lesions and rated the usefulness of each of the pre-sets. Results: Between the first (WLI-only) and second (virtual chromoendoscopy-aided) readings, in terms of accuracy there was a global 16.5 % (95 % confidence interval [95 %CI] 13.6 – 19.4 %) improvement (P < 0.001), derived from a 22 % [95 %CI 18.9 – 25.1 %] improvement in the evaluation of true ulcerative images (P < 0.001) and an 11 % (95 %CI 4.1 – 17.7 %) decrease in the evaluation of false ulcerative ones (P = 0.003). The FICE 1 and 2 pre-sets were rated as most useful. Conclusion: The application of virtual chromoendoscopy for VCE is useful to better categorize difficult-to-interpret small-bowel mucosal ulcerative lesions. However, care must be taken, and individual images should be evaluated only as part of a sequence in a recording because the technology can also mistakenly guide to the incorrect interpretation of artifacts as ulcerative lesions.

First Pillcam Colon 2 capsule images of Whipple’s disease: Case report and review of the literature

Whipples disease is a rare chronic systemic infection determined by the Gram-positive bacillus Tropheryma whipplei. The infection usually mainly involves the small bowel, but sometimes other organs are affected as well. Since the current standard clinical and biological tests are nonspecific, diagnosis is very difficult and relies on histopathology. Here we present the case of a 52-year-old man with chronic diarrhea and weight loss whose symptoms had been evolving for 2 years and whose diagnosis came unexpectedly after capsule examination. Diagnosis was confirmed by the histopathologic examination of endoscopic biopsy samples, and treatment with co-trimoxazole resulted in remission of symptoms. We present the first images of Whipples disease obtained with the Pillcam Colon 2 video capsule system.

Rapid Fecal Calprotectin Testing Predicts Mucosal Healing Better than C-reactive Protein and Serum Tumor Necrosis Factor α in Patients with Ulcerative Colitis.

Abstract Background and Aims. Serum and fecal biomarkers have been used as noninvasive methods for assessing disease activity in ulcerative colitis. C-reactive protein, serum tumor necrosis factor-α and fecal calprotectin are among the most promising such biomarkers. However, their role in the management of ulcerative colitis patients remains to be clarified. We aimed to evaluate the accuracy of C-reactive protein, fecal calprotectin and tumor necrosis factor-α in detecting clinical and endoscopic activity and predicting disease outcome. Methods. A cohort of ulcerative colitis patients was prospectively evaluated for clinical and endoscopic disease activity using the Mayo score. Serum C-reactive protein and tumor necrosis factor-α levels were measured and a point-of-care method was used for determining Calprotectin levels. Results. Fifty-three patients with ulcerative colitis were followed for a median of 12 months. Fecal calprotectin and C-reactive protein levels were significantly higher in patients with clinically active disease at baseline, but only calprotectin levels correlated with endoscopic activity. Calprotectin values over 300 μg/g had 60% sensitivity and 90% specificity for detecting active endoscopic disease and 61% sensitivity and 89% specificity for predicting mucosal healing. Conclusion. Rapid calprotectin testing is a better predictor of mucosal healing than serum biomarkers and it could improve the management of ulcerative colitis patients by decreasing the need for invasive investigations.

Trainee involvement increases precut rates and delays access to the common bile duct without an increase in procedure-related adverse events: a brave new world of ERCP training?

Abstract Background and aims. Selective cannulation of the desired duct is a key element in ERCP procedures and an important step in the training of fellows. However, there is limited data about technical success and patient safety for ERCPs conducted in a training setting.We aimed to evaluate the impact of trainee involvement on the cannulation technique and procedure related outcomes at ERCP. Materials and methods. We conducted an observational study of all ERCP conducted in an endoscopy unit with an on-going training program. Patient related data and procedure-related data (method of cannulation, time to cannulation, degree of trainee involvement, technical success and procedure-related adverse events) were collected using a standard form. The method of cannulation, time to cannulation and procedure-related adverse events were compared between ERCPs with trainee involvement and those without. Results. 641 consecutive ERCPs were evaluated and 474 native papilla cases performed by 4 trainers and 3 trainees were included in the final analysis. Trainees were involved in 171 procedures (36.1%), achieving cannulation of the desired duct in 50.8% of the cases. Cannulation rates were similar in the trainee group compared to the control group (91.7% vs. 88.7%) and there was no increase in the rate of adverse events. However, cannulation time was significantly longer in the trainee group with a significant increase in the rate of precut use (32.1% vs. 23.4%, p < 0.001). Conclusions. Trainee involvement resulted in longer cannulation times and increased use of precut sphincterotomy, but, was not associated with an increased risk of procedure related adverse events.

Preparation regimen is more important than patient-related factors: a randomized trial comparing a standard bowel preparation before colonoscopy with an individualized approach.

Abstract Background. Optimal bowel preparation is one of the most important factors affecting the quality of colonoscopy. Several patient-related factors are known to influence the quality of bowel cleansing but randomized trials in this area are lacking. We aimed to compare an individualized bowel prep strategy based on patient characteristics to a standard preparation regimen. Material and Methods. We conducted an endoscopist-blinded multicenter randomized control-trial. The Boston Bowel Prep Score (BBPS) was used to assess quality of bowel preparation and a 10 point visual analogue scale to assess patient comfort during bowel prep. Patients were randomised to either the standard regimens of split-dose 4L polyethylene-glycol (group A), split-dose sodium picosulphate/magnesium citrate (group B) or to either of the two depending on their responses to a 3-item questionnaire (individualized preparation, group C). Results. 185 patients were randomized during the study period and 143 patients were included in the final analysis. Patients in the individualized group had a median BBPS of 7 compared to a median of 6 in the standard group (p = 0.7). Also, there was no significant difference in patients’ comfort scores, irrespective of study group or laxative regimen. However, on multivariable analysis, a split-dose 4L polyethylene-glycol was an independent predictor for achieving a BBPS>6 (OR 3.7, 95% CI 1.4-9.8), regardless of patient-related factors. Conclusion. The choice of laxative seems to be more important than patient-related factors in predicting bowel cleansing. Comfort during bowel prep is not influenced by the type of strategy used.

Factors Influencing Complication Rates at Colonic Polypectomy: A Prospective Study from a Tertiary-Referral Center.

Abstract Background and aims. Colon polypectomy decreases the incidence of colorectal cancer and related mortality. Several factors such as the size, location and type of polyp as well as endoscopist experience have been shown to correlate with the risk of ensuing procedure-related complications. This study aims to evaluate the impact of polyp and endoscopist-related factors on the rate of postpolypectomy complication in a real-life setting. Methods. During the study period all polypectomies performed in our unit were reported on a standard form that included data on polyp type (flat, sessile, pedunculated), size, location in the colon, resection method, endoscopist volume and procedure-related complications arising up to 30 days. The main outcome was the complication rate of polypectomies. The factors that associated with a higher risk of complications were assessed on univariate and multivariate analysis. Results. 244 polyp resections from 95 patients were included in the analysis. 199 polyps were resected by low-volume endoscopists (44.7%) and 135 polypectomies were performed by highvolume endoscopists (55.3%). On multivariate analysis only polyp size correlated with the risk of procedure-related complications. Conclusion. Polyp size is the most important risk factor for procedure-related complications. Both high and low-volume endoscopists have a low overall rate of serious complications. Abstract Polipectomia endoscopică colonică scade incidenţa şi mortalitatea prin cancer colorectal. Mai mulţi factori cum ar fi mărimea polipilor, localizarea şi tipul acestora precum şi experienţa endoscopistului au fost corelate cu rata de complicaţii postprocedurale. Studiul de faţă îşi propune să evalueze impactul factorilor dependenţi de polip şi de endoscopist asupra ratei de complicaţii după polipectomie în practica curentă. Metode. Pe durata desfăşurării studiului toate polipectomiile efectuate în unitatea noastră au fost raportate folosind un formular standard incluzând date despre tipul polipului (sesil, pediculat, plat), dimensiunile şi localizarea acestuia, metoda de rezecţie, experienţa endoscopistului şi complicaţiile procedurale survenite până la 30 de zile de la polipectomie. Principalul obiectiv a fost indentificarea ratei de complicaţii legate de polipectomia endoscopică. Factorii corelaţi cu aceste complicaţii au fost analizaţi utilizând analiză uni şi multivariată. Rezultate. 244 de polipectomii efectuate la 95 de pacienţi au fost incluse în analiză. 199 de polipi au fost rezecaţi de endoscopişti în pregătire (44,7%) şi 135 de polipectomii au fost efectuate de endoscopişti experimentaţi (55,3%). La analiza multivariată doar dimensiunea polipilor s-a corelat cu riscul de complicaţii postpolipectomie. Concluzii. Dimensiunea polipilor este cel mai important factor de risc pentru complicaţii postprocedurale, rata complicaţiilor postpolipectomie fiind scăzută atât pentru endoscopiştii experimentaţi cât şi pentru cei aflaţi în pregătire.