Cristina Carretero

Capsule endoscopy versus colonoscopy for the detection of polyps and cancer.

BACKGROUND An ingestible capsule consisting of an endoscope equipped with a video camera at both ends was designed to explore the colon. This study compared capsule endoscopy with optical colonoscopy for the detection of colorectal polyps and cancer. METHODS We performed a prospective, multicenter study comparing capsule endoscopy with optical colonoscopy (the standard for comparison) in a cohort of patients with known or suspected colonic disease for the detection of colorectal polyps or cancer. Patients underwent an adapted colon preparation, and colon cleanliness was graded from poor to excellent. We computed the sensitivity and specificity of capsule endoscopy for polyps, advanced adenoma, and cancer. RESULTS A total of 328 patients (mean age, 58.6 years) were included in the study. The capsule was excreted within 10 hours after ingestion and before the end of the lifetime of the battery in 92.8% of the patients. The sensitivity and specificity of capsule endoscopy for detecting polyps that were 6 mm in size or bigger were 64% (95% confidence interval [CI], 59 to 72) and 84% (95% CI, 81 to 87), respectively, and for detecting advanced adenoma, the sensitivity and specificity were 73% (95% CI, 61 to 83) and 79% (95% CI, 77 to 81), respectively. Of 19 cancers detected by colonoscopy, 14 were detected by capsule endoscopy (sensitivity, 74%; 95% CI, 52 to 88). For all lesions, the sensitivity of capsule endoscopy was higher in patients with good or excellent colon cleanliness than in those with fair or poor colon cleanliness. Mild-to-moderate adverse events were reported in 26 patients (7.9%) and were mostly related to the colon preparation. CONCLUSIONS The use of capsule endoscopy of the colon allows visualization of the colonic mucosa in most patients, but its sensitivity for detecting colonic lesions is low as compared with the use of optical colonoscopy. (ClinicalTrials.gov number, NCT00604162.)

Second-generation colon capsule endoscopy compared with colonoscopy

BACKGROUND Colon capsule endoscopy (CCE) represents a noninvasive technology that allows visualization of the colon without requiring sedation and air insufflation. A second-generation colon capsule endoscopy system (PillCam Colon 2) (CCE-2) was developed to increase sensitivity for colorectal polyp detection compared with the first-generation system. OBJECTIVE To assess the feasibility, accuracy, and safety of CCE-2 in a head-to-head comparison with colonoscopy. DESIGN AND SETTING Prospective, multicenter trial including 8 European sites. PATIENTS This study involved 117 patients (mean age 60 years). Data from 109 patients were analyzed. INTERVENTION CCE-2 was prospectively compared with conventional colonoscopy as the criterion standard for the detection of colorectal polyps that are ≥6 mm or masses in a cohort of patients at average or increased risk of colorectal neoplasia. Colonoscopy was independently performed within 10 hours after capsule ingestion or on the next day. MAIN OUTCOME MEASUREMENTS CCE-2 sensitivity and specificity for detecting patients with polyps ≥6 mm and ≥10 mm were assessed. Capsule-positive but colonoscopy-negative cases were counted as false positive. Capsule excretion rate, level of bowel preparation, and rate of adverse events also were assessed. RESULTS Per-patient CCE-2 sensitivity for polyps ≥6 mm and ≥10 mm was 84% and 88%, with specificities of 64% and 95%, respectively. All 3 invasive carcinomas were detected by CCE-2. The capsule excretion rate was 88% within 10 hours. Overall colon cleanliness for CCE-2 was adequate in 81% of patients. LIMITATIONS Not unblinding the CCE-2 results at colonoscopy; heterogenous patient population; nonconsecutive patients. CONCLUSION In this European, multicenter study, CCE-2 appeared to have a high sensitivity for the detection of clinically relevant polypoid lesions, and it might be considered an adequate tool for colorectal imaging.

Gastroduodenal Injury After Radioembolization of Hepatic Tumors

BACKGROUND:Radioembolization is a new tool for the treatment of hepatic tumors that consists in the injection of biocompatible microspheres carrying radioisotopes into the hepatic artery or its branches.METHODS:We have performed radioembolization in 78 patients with hepatic tumors using resin-based microspheres loaded with yttrium-90. All patients were previously evaluated to minimize the risk of hazardous irradiation to nontarget organs and to obtain the data needed for dose calculation.RESULTS:We report a complication found in three cases (3.8%) that consists of abdominal pain resulting from gastroduodenal lesions and that had a chronic, insidious course. Microscopically, microspheres were detected in the specimens obtained from all affected gastric areas. Since these gastroduodenal lesions do not appear when nonradiating microspheres are injected in animals, lesions are likely to be due to radiation and not to an ischemic effect of vascular occlusion by spheres.CONCLUSIONS:We believe that a pretreatment evaluation that includes a more thorough scrutiny of the hepatic vascularization in search of small collaterals connecting to the gastroduodenal tract can help prevent this awkward complication.

Long-term follow-up study of gastroduodenal lesions after radioembolization of hepatic tumors

AIM To evaluate the long-term natural history of the gastroduodenal lesions secondary to extrahepatic embolization with Ytrium 90 (⁹⁰Y) spheres. METHODS From September 2003 to January 2012, 379 procedures of liver radioembolization (RE) using resin microspheres loaded with ⁹⁰Y were performed in our center. We have retrospectively compiled the data from 379 RE procedures performed in our center. We report a comprehensive clinical, analytical, endoscopic and histologic long-term follow-up of a series of patients who developed gastroduodenal lesions after the treatment. RESULTS Six patients (1.5%) developed gastrointestinal symptoms and had gastrointestinal lesions as shown by upper endoscopy in the next 12 wk after RE. The mean time between RE and the appearance of symptoms was 5 wk. Only one patient required endoscopic and surgical treatment. The incidence of gastrointestinal ulcerations was 3.75% (3/80) when only planar images were used for the pre-treatment evaluation. It was reduced to 1% (3/299) when single-photon emission computed tomography (SPECT) images were also performed. The symptoms that lasted for a longer time were nausea and vomiting, until 25 mo after the treatment. CONCLUSION All patients were free from severe symptoms at the end of follow-up. The routine use of SPECT has decreased the incidence of gastrointestinal lesions due to unintended deployment of ⁹⁰Y particles.

Therapeutic impact of colon capsule endoscopy with PillCam™ COLON 2 after incomplete standard colonoscopy: a Spanish multicenter study.

INTRODUCTION Colon capsule endoscopy (CCE) is an alternative approach for the examination of the colon in patients who refuse colonoscopy or after incomplete colonoscopy (IC). We conducted a study to determine the frequency of complete colonoscopy after IC, the diagnostic yield of CCE, the therapeutic impact of lesions found in CCE, the level of colon cleanliness and the safety of the procedure. METHODS We performed a prospective, multicenter study involving ten Spanish hospitals. Consecutive outpatients aged ≥ 18 years with previous IC were invited to participate. The latest version of the CCE device, PillCam™ COLON 2 (CCE-2), was administered to all patients according to the protocol. RESULTS The study population comprised 96 patients. The most frequent cause of IC was the inability to move past a loop using standard maneuvers (75/96 patients, 78%). Complete visualization of the colon was obtained with CCE-2 in 69 patients (71.9%). Of the 27 patients in whom the CCE-2 did not reach the hemorrhoidal plexus, it passed the colonic segment explored with the previous colonoscopy in 20 cases; therefore, it could be inferred that a combined approach (CCE-2 plus colonoscopy) enabled complete visualization of the colonic mucosa in 92.7% of patients. CCE-2 revealed new lesions in 58 patients (60.4%). Polyps were the most frequent finding (41 patients; 42.7% of the total number of patients). In 43 of the 58 patients (44.8% of the total number of patients), the new lesions observed led to modification of therapy, which included a new colonoscopy for polyp resection or surgery in patients with colonic neoplasm. CONCLUSIONS CCE-2 is a suitable diagnostic procedure that can lead to more frequent diagnosis of significant colonic lesions after IC.

Comparative study of a responsive insertion technology (RIT) colonoscope versus a variable-stiffness colonoscope

BACKGROUND AND OBJECTIVES recently, Olympus developed a new prototype (XCF-Q180AY2L) with responsive insertion technology (RIT), which besides the still known variable stiffness technology, included a passive bending section and a new high force insertion tube. Our objective was to investigate whether the use of this prototype could ease colonoscope insertion, increasing the cecal intubation rate, and/or shortening the cecal intubation time. MATERIAL AND METHODS the study was designed as a prospective observational study in 305 consecutive patients from a colo-rectal cancer screening program. We compared colonoscopies performed with conventional colonoscopes (CFH180AL/CFQ160L) with those performed with the prototype XCF-Q180AY2L. End points were mean cecal and terminal ileal intubation times, cecum intubation rate, and need for specific maneuvers. All colonoscopies were performedunder sedation with intravenous propofol. Finally, 288 patients were included. RESULTS no complications were observed. Complete cecal intubation rate was 100 % in both groups. The ileum could be reached in 98.95 % of cases. Mean time required to reach the cecum was shorter in the prototype endoscope group (4.31 min, SD 2.63 min) than in the conventional endoscope group (4.66 min, SD 2.52 min) (p < 0.05). Compared with the standard colonoscope group, we observed in the prototype group less subjective sensation of difficultyin the passage of the sigma (p < 0.01), fewer maneuvers when it proved necessary to straighten the scope (p < 0.01), and less frequent need to modify the stiffness of the endoscope (p < 0.05). CONCLUSION we concluded that the prototype endoscope (XCFQ180AY2L) facilitated colonoscope insertion, requiring slightly less time to reach the cecum than a standard colonoscope.

Isolated dysphagia due to paraneoplastic myasthenic syndrome with anti-P/Q-type voltage-gated calcium-channel and anti-acetylcholine receptor antibodies.

Dysphagia is a common symptom in neuromuscular junction disorders, but it rarely occurs in isolation or is the presenting feature. We describe a patient presenting with isolated dysphagia to liquids. Electrophysiological studies, such as repetitive nerve stimulation and single-fiber electromyography, were normal. Serum anti-P/Q-type voltage-gated calcium-channel (anti-P/Q-type VGCC) and anti-acetylcholine receptor (AChR ab) antibodies were above the normal range. A computed tomography scan showed a mediastinal mass corresponding to a thymic carcinoma. After chemotherapy, surgical removal of the thymic carcinoma and radiotherapy, the patient no longer complained of dysphagia, AChR ab titers were reduced and anti-P/Q-type VGCC antibodies became negative. To the best of our knowledge, no previous reports of a paraneoplastic myasthenic syndrome related to thymic carcinoma with both anti-P/Q-type VGCC and AChR antibodies have been described.

Utilidad de la endoscopia en la hemorragia digestiva por vasculitis

Vasculitides constitute a heterogeneous group of diseases characterized by inflammation of blood vessels. The skin is mainly affected, although the gastrointestinal tract mucosa can also be involved. The contribution of endoscopy in these cases has not been clearly determined. We report three cases of systemic vasculitis (polyarteritis nodosa, Schonlein-Henoch purpura and Behcets disease) presenting with acute digestive bleeding. Endoscopy was an effective technique for completing the diagnosis and in establishing an effective nonsurgical therapeutic approach in these potentially lethal cases of gastrointestinal hemorrhage.

Blue Rubber Bled Nevus syndrome: three cases

Syndrome (BRBNS) have been diagnosed in our center. In the younger patients (18 and 49-year old), endoscopic examinations were indicated because of the presence of iron deficiency anemia (IDA); in the older patient (77year old), endoscopy was performed because of hematochezia without laboratory or clinical involvement. In all patients, we observed nodular, bluish, tender, wrinkled or slightly depressed lesions at the skin and gastrointestinal (GI) tract. Most severe cutaneous lesions were observed on the upper limbs of the older patient (Fig. 1). On the other hand, endoscopic examinations of patients with IDA showed many of these lesions throughout the GI tract, and the greater ones were located in the colon (Figs. 2 and 3). Because of the symptoms of these three patients were mild, they were treated with conservative measures. Outcome was favorable in all cases. BRBNS, also known as Bean ́s syndrome, is a rare and probably inherited disorder characterized by the presence of cutaneous hemangiomas and vascular tumors of the GI tract (1,2). The lesions in the GI tract are usually multiple and may involve Blue Rubber Bled Nevus syndrome: three cases

Estudio de la frecuencia, distribución y rendimiento diagnóstico en las lesiones neoplásicas sincrónicas del carcinoma colo-rectal

Aim. To analyse the frequency, characteristics and diagnosis of synchronic neoplastic lesions in colorectal cancer. Methods. A review was carried out of 384 colorectal cancers, diagnosed through complete colonoscopy and resected. The synchronic cancers and the characteristics of the adenomas were determined: number, size, histological type, dysplasia, as well as their localisation in the colon and with respect to the carcinoma. Results. Twenty-eight synchronic cancers were found (7.3% of the total); 8 developed tumours and 20 malignant polyps. In 54.4% of the cases there was a synchronic adenoma. In patients with synchronic lesions, 43% showed an advanced adenoma. Twenty percent of the synchronic polyps found were proximal to the splenic flexure; 41% were distal and 38% had both localisations. Fifty-nine point one percent of the patients had some adenoma proximal to the cancer, with criteria of advanced adenoma in 13.9%. The distribution of the adenomas was more uniformly spread in the cancers with a proximal localisation (p = 0.038). Seventeen percent of the distal cancers presented synchronic lesions with a proximal colon localisation exclusively. Partial endoscopies would diagnose the distal cancers, but would omit a synchronic adenoma in 42.3% of the sigmoidoscopies and 40% of the short colonoscopies. Conclusions. High rates of carcinoma and synchronic adenomas were registered. We underline the high index of advanced adenomas and the frequency of synchronic lesions proximal to the cancer, which is why incomplete colonoscopies, although allowing the diagnosis of the distal cancer, omit a high percentage of synchronic adenomas, including advanced lesions. All of this confirms the need to perform a complete pre-, intra- and post operational colonoscopy in resectable colorectal cancer.