Dimitri Coumaros

Miss rate for colorectal neoplastic polyps: a prospective multicenter study of back-to-back video colonoscopies.

BACKGROUND AND STUDY AIM Polyp miss rates during colonoscopy have been calculated in a few tandem or back-to-back colonoscopy studies. Our objective was to assess the adenoma miss rate while limiting technique or operator expertise biases, i. e. by performing a large multicenter study, with same-day back-to-back video colonoscopy, done by two different operators in randomized order and blinded to the other examination. PATIENTS AND METHODS 294 patients at 11 centers were included. Among the 286 analyzable tandem colonoscopies, miss rates were calculated in both a lesion- and patient-based analysis. Each of these rates was determined for polyps overall, for adenomas, and then for lesions larger than 5 mm, and for advanced adenomas. Univariate and logistic regression analysis were performed to define independent variables associated with missed polyps or adenomas. RESULTS The miss rates for polyps, adenomas, polyps > or = 5 mm, adenomas > or = 5 mm, and advanced adenomas were, respectively, 28 %, 20 %, 12 %, 9 % and 11 %. None of the masses with a carcinomatous (n = 3) or carcinoid component (n = 1) was missed. The specific lesion miss rates for patients with polyps and adenomas were respectively 36 % and 26 % but the corresponding rates were 23 % and 9.4 % when calculated for all 286 patients. The diameter (1-mm increments) and number of polyps (> or = 3) were independently associated with a lower polyp miss rate, whereas sessile or flat shape and left location were significantly associated with a higher miss rate. Adequacy of cleansing, presence of diverticula, and duration of withdrawal for the first procedure were not associated with adenoma miss rate. CONCLUSIONS We confirm a significant miss rate for polyps or adenoma during colonoscopy. Detection of flat polyps is an issue that must be focused on to improve the quality of colonoscopy.

Natural Orifice Transluminal Endoscopic Surgery: Transgastric Cholecystectomy in a survival porcine model

Beyond doubt, laparoscopic cholecystectomy has changed the focus of surgery and the mind-set of nearly all surgeons. For this reason, the initial natural orifices translumenal endoscopic surgery (NOTES) project focused on cholecystectomy, which seemed to be the most logical and appealing clinical application. The first reports on cholecystectomy confirmed the feasibility of NOTES but identified substantial technical limits because of exposure, endoscope stability issues, and limitations in the control of dissection tools [1, 2]. These limitations led to experimentation with other natural orifice accesses: the colon, the urinary bladder, and combined routes [3, 4]. Although transcolonic cholecystectomy has been reported in survival studies, to date, the feasibility of transgastric cholecystectomy has been described only in nonsurvival animal models [1, 2, 5]. We report the successful performance of transgastric cholecystectomy with survival in a porcine model.

Capsule endoscopy and bowel preparation with oral sodium phosphate: a prospective randomized controlled trial

BACKGROUND Capsule endoscopy (CE) is the first procedure to explore the small bowel in obscure GI bleeding (OGB). OBJECTIVE To evaluate the role of bowel preparation with oral sodium phosphate (NaP) in this indication. DESIGN A prospective multicenter, controlled, randomized, blind study. METHODS A total of 129 patients with the diagnosis of OGB were included and were randomized into 2 groups (group A [n = 64] and group B [n = 63]). In group A, a CE was performed after an 8-hour fasting period. In group B, patients were asked to drink 2 doses of 45 mL NaP before swallowing the capsule. The quality of the images was assessed at 5 different locations of the small bowel. Bowel cleanliness and visibility were evaluated by using 2 scoring systems, which included assessing the presence of bubbles, liquid, and the rate of visibility. RESULTS A total of 127 patients (53 men; mean age 56.9 years, range 19-90 years) were analyzed for the preparation and detection of lesions (2 patients were not able to swallow the capsule). No difference was observed for cleanliness and visibility between the 2 groups at any of the small-bowel segments; no difference was found for gastric transit time (39.8 minutes vs 35.7 minutes, P = .63), small-bowel transit time (257.5 minutes vs 248.6 minutes, P = .59), and the detection of lesions (35.9% vs 42.8%, P = .54). LIMITATIONS The evaluation of bowel cleanliness was based on subjective features. CONCLUSIONS The results of the present study, despite a significant number of limitations, did not support that small-bowel preparation with oral NaP can be recommended for CE exploration in patients with OGB.

Endoscopic papillectomy for early ampullary tumors: long-term results from a large multicenter prospective study.

BACKGROUND AND STUDY AIMS Endoscopic papillectomy of early tumors of the ampulla of Vater is an alternative to surgery. This large prospective multicenter study was aimed at evaluating the long-term results of endoscopic papillectomy. PATIENTS AND METHODS Between September 2003 and January 2006, 10 centers included all patients referred for endoscopic papillectomy and meeting the inclusion criteria: biopsies showing at least adenoma, a uT1N0 lesion without intraductal involvement at endoscopic ultrasound (EUS), and no previous treatment. A standardized endoscopic papillectomy was done, with endoscopic monitoring with biopsies 4 - 8 weeks later where complications were recorded and complementary resection performed when necessary. Follow-up with duodenoscopy, biopsies, and EUS was done at 6, 12, 18, 24 and 36 months. Therapeutic success was defined as complete resection (no residual tumor found at early monitoring) without duodenal submucosal invasion in the resection specimen in the case of adenocarcinoma and without relapse during follow-up. RESULTS 93 patients were enrolled. Mortality was 0.9 % and morbidity 35 %, including pancreatitis in 20 %, bleeding 10 %, biliary complications 7 %, perforation 3.6 %, and papillary stenosis in 1.8 %. Adenoma was not confirmed in the resection specimen in 14 patients who were therefore excluded. Initial treatment was insufficient in 9 cases (8 carcinoma with submucosal invasion; 1 persistence of adenoma). During follow-up, 5 patients had tumor recurrence and 7 died from unrelated diseases without recurrence. Finally, 81.0 % of patients were cured (95 % confidence interval 72.3 % - 89.7 %). CONCLUSION Endoscopic papillectomy of selected ampullary tumors is curative in 81.0 % of cases. It must be considered to be the first-line treatment for early tumors of the ampulla of Vater without intraductal invasion.

Long-term follow-up of patients undergoing capsule and double-balloon enteroscopy for identification and treatment of small-bowel vascular lesions: a prospective, multicenter study

BACKGROUND AND STUDY AIMS Few data are available concerning the long-term outcome of patients treated endoscopically for bleeding small-bowel vascular lesions (SBVL). The aim of this study was to evaluate the risk of rebleeding after endoscopic therapy for SBVLs detected by video capsule enteroscopy (VCE). The secondary aim was to assess risk factors for rebleeding. PATIENTS AND METHODS A prospective, multicenter study (15 centers) was conducted, involving patients with obscure gastrointestinal bleeding and SBVL on VCE who were treated during double-balloon enteroscopy (DBE). The likelihood of bleeding was defined according to VCE findings, as high or low. RESULTS A total of 183 patients underwent endotherapy during DBE, and 64 (35 %) had rebleeding during the 1 year follow-up period. Multivariate analysis indicated that cardiac disease (hazard ratio [HR] 2.04, 95 % confidence interval [CI] 1.20 - 3.48; P < 0.01) and the presence of overt bleeding (HR 1.78, 95 %CI 1.07 - 2.97; P = 0.03) at presentation were associated with the risk of rebleeding. The association between chronic renal failure and the risk of rebleeding was close to statistical significance (HR 1.77, 95 %CI 0.94 - 3.33; P = 0.08). Kaplan-Meier analysis suggested that patients treated during DBE for a lesion with low likelihood of bleeding on VCE had higher rebleeding rates than those with a high likelihood of bleeding (HR 1.87, 95 %CI 0.94 - 3.37; P = 0.07). CONCLUSION Despite long-term remission in most patients, about one-third had rebleeding at 1 year. Independent risk factors for rebleeding were cardiac disease and overt bleeding at original presentation. The lesion characteristics on VCE may be useful to evaluate the bleeding potential of the lesion and may be used for better selection of patients for DBE.

Joystick Interfaces Are Not Suitable for Robotized Endoscope Applied to NOTES

Background NOTES has changed the working environment of endoscopy, leading to new difficulties. The limitations of conventional endoscopes call for the development of new platforms. Robotics may be the answer. Materials and methods The authors compared human to robotized manipulation of a flexible endoscope into the abdominal cavity, in an animal model. Thirty-two participants were enrolled. Results were analyzed according to the clinical background of the participants: experienced endoscopists, experienced laparoscopists, and medical students. Two single-channel gastroscopes were used. Whereas one was not modified, the other had the handling wheels replaced by motors controlled through a computer and a joystick. A NOTES transgastric approach was used to access the peritoneal cavity. The time to touch previously positioned intra-abdominal numbered plastic targets was recorded 3 times with each endoscope. Results Mean time to complete the tasks was significantly shorter using the conventional endoscope (2.71 vs 6.96 minutes, P < .001). When the robotized endoscope was used, the mean times of endoscopists (7.42 minutes), laparoscopists (6.84 minutes), and students (6.77 minutes) were statistically identical. No differences were found between laparoscopists and students in both techniques. Discussion Applying robotics to a flexible endoscope fails to enhance ability to move into the abdominal cavity, partly because of the interface. To overcome the limitations of endoscope when performing complex NOTES tasks, robotics may be useful, especially to control the instruments and to stabilize the endoscope itself. Conclusion Robotized endoscope with joystick interface is not sufficient to enhance immediate intuitiveness of flexible endoscopy applied to NOTES.

Comparison of a standard fully covered stent with a super-thick silicone-covered stent for the treatment of refractory esophageal benign strictures: A prospective multicenter study

Background Some esophageal strictures resist endoscopic treatments. There is a need for new treatments, such as specifically designed stents. Objective Our study sought to compare the results achieved with a standard, fully covered metallic stent (FCMS) and those achieved using a stent designed specifically for benign strictures (BS-FCMS). Patients and methods The study used a prospective, multicenter, controlled design, with patients recruited from tertiary referral centers. Patients with refractory esophageal strictures were included. Standard FCMS were used in group 1 (N = 24), and BS-FCMS were used in group 2 (N = 17). Patients were followed for 24 months after stent removal. The main outcomes measured were stricture resolution rate, 24 months’ recurrence rate and stent-related morbidity. Results Early stent migrations occurred in one (4.1%) patient from group 1 and five (29.4%) from group 2 (p < 0.05). During esophageal stenting, complications occurred in six patients (25%) in group 1 and six patients (35.3%) in group 2 (p = 0.47), respectively. Fifty percent of complications were attributed to migration. There was no procedure-related morbidity associated with the extraction of the stent. The stricture resolution rate was, respectively, 95.2% in group 1 and 87.5% in group 2 (the difference between the two groups is not significant). During follow-up, stricture recurrence occurred in 15/19 patients (group 1, 79%) and 7/8 patients (group 2, 87.5%; p = 1.0). The median time to recurrence of esophageal stricture was 1.7 months (group 1, 0.6–12 months) and 1 month (group 2, 0.1–6 months). Study limitations include its nonrandomized design. Conclusion The stricture resolution rate was high at the end of the stenting period for both types of stents without any statistical difference between the two groups, but the long-term results were disappointing, with stricture recurring frequently and rapidly in both groups.

Endoscopic management of a tubular esophageal duplication diagnosed in adolescence (with videos )

BACKGROUND Esophageal duplication is a rare congenital lesion. Surgery is the standard treatment. Tubular duplication is extremely rare, with esophageal communication in very few cases. OBJECTIVE The aim of this study was to document the feasibility of the endoscopic management of tubular esophageal duplication. DESIGN Case report. INTERVENTION A 14-year-old boy presented with acute dysphagia and acute retrosternal pain. Based on his radiographic and endoscopic findings, a cystic esophageal duplication with an upper esophageal stricture was initially suspected. A laparoscopic gastrostomy was performed. A cyst resection through right thoracoscopy assisted by flexible endoscopy was decided upon. When no extraluminal cystic duplication was found, a tubular duplication was considered and the procedure was abandoned. An endoscopic treatment was performed. A standard endoscope was inserted through an upper esophageal stricture. Two lumens were identified 25 cm from the incisors. A pediatric endoscope was passed through the main one, revealing a thick intraluminal bridge. By using a guidewire, the endoscopes passage into the narrow lumen revealed a distal communication with the esophagus. With the guidewire left in place, the endoscope was reintroduced into the main lumen. A lengthwise incision of the bridge was performed by using a needle knife. At the end of the procedure, an esophageal dilation was performed. Histology confirmed the diagnosis of duplication. RESULTS The endoscopic incision of the duplication was completed uneventfully. For 11 months, the patient followed a normal diet and experienced no symptoms. LIMITATIONS Single case. CONCLUSION To our knowledge, this is the first report of successful endoscopic incision of a total tubular esophageal duplication.

Diagnostic Value of Capsule Endoscopy (CE) in Obscure Digestive Bleeding (ODB) and Effect of Erythromycin Injection

Diagnostic Value of Capsule Endoscopy (CE) in Obscure Digestive Bleeding (ODB) and Effect of Erythromycin Injection Dimitri Coumaros, Laurent Claudel, Patrick Levy, Michel Doffoel Aims : Evaluate the diagnostic yield of CE in ODB and the effect of erythomycin injection. Patients andmethods: In this prospective randomized study, 37 patients (pts) (mean age : 61 years) with an occult (n = 19) or overt (n = 18) ODB, were investigated by the Given M2A capsule, with (n = 19) or without (n = 18) intravenous injection of 3 mg/kg erythomycin, 30 to 60 min before CE. Colonic cleansing with 4 L PEG (n= 34) or 2 bottles of sodium phosphate (n = 3) ending 1 h before CE was undertaken. Lesions were classified according to their bleeding potential : nil (L0), probable (L1) or certain (L2) if an active bleedingwas visible. A single diagnosis per patient was delivered. Diagnostic agreement coefficient between a senior and a junior endoscopist was calculated based on 21 examinations. Gastric and small bowel transit times as well as the possibility of visualizing the colon were compared between the 2 groups. The duration of video analysis was measured. Results : 36 examinations out of 40 were valid (3 technical failures, 1 prolonged retention in the lower esophagus). The examination of 3 pts was repeated. 72 lesions L1 and 2 L2 were detected in 30 pts (83%). These pts had one type of lesion (n = 11), 2 (n = 15) or 3 types of different lesion (n = 4). The resulting diagnosis was angiectasias (n = 14), ulcerations (n = 7), red spots (n = 5), varix (n= 1), tumor (n= 1), nematodes (n= 1), polypoid angiectasia (n= 1). The location of these lesions was jejuno-ileal (n = 23), duodenal (n = 3), gastric (n = 1), colonic (n = 1) or multifocal (n = 2). The interobserver kappa coefficient was 0.64. The presence of red spots was linked to the presence of angiectasias (p<0.001). Erythromycin decreased the gastric time by 55 min (p<0.01) and increased the small bowel time by 70 min (p<0.03) without change of the rate of complete examination of the small bowel (84 vs 80%). Colonic visualization was allways limited to the caecum and ascending colon. Colonic cleansing was insufficient in 89% of pts. The duration of the video analysis decreased significantly after the first 24 examinations (63 vs 80 min; p<0.02). 2 cases of oral time superior to 5 min and 1 temporary blocage of the CE in the hypopharynx were noted. Conclusion : CE detected a bleeding or a potential bleeding lesion in 83% of pts. The resulting diagnosis concerned the stomach, the duodenum or the colon in 14% of the pts. Erythromycin reduced the gastric time without increasing the rate of complete examination of the small bowel. The exploration of the colon was limited to the caecum and ascending colon.

The expansion of endoscopic submucosal dissection in France: A prospective nationwide survey

Introduction Early reports of endoscopic submucosal dissection (ESD) in Europe suggested high complication rates and disappointing outcomes compared to publications from Japan. Since 2008, we have been conducting a nationwide survey to monitor the outcomes and complications of ESD over time. Material and methods All consecutive ESD cases from 14 centers in France were prospectively included in the database. Demographic, procedural, outcome and follow-up data were recorded. The results obtained over three years were compared to previously published data covering the 2008–2010 period. Results Between November 2010 and June 2013, 319 ESD cases performed in 314 patients (62% male, mean (±SD) age 65.4 ± 12) were analyzed and compared to 188 ESD cases in 188 patients (61% male, mean (±SD) age 64.6 ± 13) performed between January 2008 and October 2010. The mean (±SD) lesion size was 39 ± 12 mm in 2010–2013 vs 32.1 ± 21 for 2008–2010 (p = 0.004). En bloc resection improved from 77.1% to 91.7% (p < 0.0001) while R0 en bloc resection remained stable from 72.9% to 71.9% (p = 0.8) over time. Complication rate dropped from 29.2% between 2008 and 2010 to 14.1% between 2010 and 2013 (p < 0.0001), with bleeding decreasing from 11.2% to 4.7% (p = 0.01) and perforations from 18.1% to 8.1% (p = 0.002) over time. No procedure-related mortality was recorded. Conclusions In this multicenter study, ESD achieved high rates of en bloc resection with a significant trend toward better outcomes over time. Improvements in lesion delineation and characterization are still needed to increase R0 resection rates.