Francisco C. Ramirez

Comparison of the yield and miss rate of narrow band imaging and white light endoscopy in patients undergoing screening or surveillance colonoscopy: a meta-analysis.

OBJECTIVES:Colonoscopy has an appreciable miss rate for adenomas and colorectal cancer. The goal of advanced endoscopic imaging is to improve lesion detection. Compared with standard definition, high-definition (HD) colonoscopes have the advantage of increased field of visualization and higher resolution; narrow band imaging (NBI) utilizes narrow band filters for enhanced visualization of surface architecture and capillary pattern. The objective of this study was to compare the yield and miss rates of HD-NBI and HD-WLE (white light endoscopy) for the detection of colon polyps using meta-analysis.METHODS:A recursive literature search of randomized controlled trials (RCTs) comparing the yield of HD-NBI and HD-WLE for detection of colon polyps in patients undergoing screening/surveillance colonoscopy. Authors were contacted for missing data. In RCT with tandem colonoscopy (RCT-t), findings from the first-pass examinations were used in the yield analysis and from the tandem pass for the miss rate analysis. Data on the yield of polyps were extracted, pooled, and analyzed using RevMan 4.2.9 software. Odds ratio (OR) and 95% confidence intervals (CIs) for the pooled data for the yield and miss rates of NBI and WLE were calculated. A fixed effect model (FEM) was used for analyses without, and a random effect model (REM) for analyses with heterogeneity.RESULTS:The yield analysis revealed no significant difference between HD-NBI and HD-WLE for the detection of adenomas (six studies; n=2,284; OR: 1.01; CI: 0.74–1.37; REM); patients with polyps (six studies; n=2,275; OR: 1.15; CI: 0.8–1.64; REM); patients with adenomas (four studies; n=2,177; OR: 1.0; CI: 0.83–1.20; FEM); detection of adenomas <10u2009mm (five studies; n=1,618; OR: 1.32; CI: 0.92–1.88; FEM); flat adenomas (five studies; n=1,675; OR: 1.26; CI: 0.62–2.57; REM); and flat adenomas per patient (five studies; n=2,200; OR: 1.63; CI: 0.71–3.74; REM). The miss rate analysis revealed no difference in polyp miss rate (three studies; n=524; OR: 1.17; CI: 0.8–1.71; FEM) or adenoma miss rate (three studies; n=524; OR: 0.65; CI: 0.4–1.06; FEM) between the two techniques.CONCLUSIONS:Compared with HD-WLE, HD-NBI does not increase the yield of colon polyps, adenomas, or flat adenomas, nor does it decrease the miss rate of colon polyps or adenomas in patients undergoing screening/surveillance colonoscopy.

Water-aided colonoscopy: a systematic review

BACKGROUNDnWater-aided methods for colonoscopy are distinguished by the timing of removal of infused water, predominantly during withdrawal (water immersion) or during insertion (water exchange).nnnOBJECTIVEnTo discuss the impact of these approaches on colonoscopy pain and adenoma detection rate (ADR).nnnDESIGNnSystematic review.nnnSETTINGnRandomized, controlled trial (RCT) that compared water-aided methods and air insufflation during colonoscope insertion.nnnPATIENTSnPatients undergoing colonoscopy.nnnINTERVENTIONnMedline, PubMed, and Google searches (January 2008-December 2011) and personal communications of manuscripts in press were considered to identify appropriate RCTs.nnnMAIN OUTCOME MEASUREMENTSnPain during colonoscopy and ADR. RCTs were grouped according to whether water immersion or water exchange was used. Reported pain scores and ADR were tabulated based on group assignment.nnnRESULTSnPain during colonoscopy is significantly reduced by both water immersion and water exchange compared with traditional air insufflation. The reduction in pain scores was qualitatively greater with water exchange as compared with water immersion. A mixed pattern of increases and decreases in ADR was observed with water immersion. A higher ADR, especially proximal to the splenic flexure, was obtained when water exchange was implemented.nnnLIMITATIONSnDifferences in the reports limit application of meta-analysis. The inability to blind the colonoscopists exposed the observations to uncertain bias.nnnCONCLUSIONnCompared with air insufflation, both water immersion and water exchange significantly reduce colonoscopy pain. Water exchange may be superior to water immersion in minimizing colonoscopy discomfort and in increasing ADR. A head-to-head comparison of these 3 approaches is required.

Increased adenoma detection rate with system-wide implementation of a split-dose preparation for colonoscopy

BACKGROUNDnRecent studies using split-dose preparations (SDPs) suggest a significant improvement in the quality of preparation and patient compliance. However, the effects of SDP on other quality indicators of colonoscopy, such as cecal intubation and adenoma detection rates, have not been previously reported, to our knowledge.nnnOBJECTIVEnThe primary objective of this study was to compare polyp detection rates (PDRs) and adenoma detection rates (ADRs) before and after the implementation of an SDP as the preferred bowel preparation. The secondary objectives were to compare the quality of the preparation and colonoscopy completion rates before and after implementation of the SDP.nnnDESIGNnRetrospective study.nnnSETTINGnTertiary care medical center.nnnPATIENTSnPatients undergoing colonoscopy for screening and surveillance of colon polyps and cancer.nnnINTERVENTIONSnSystem-wide implementation of SDP.nnnRESULTSnA total of 3560 patients in the pre-SDP group and 1615 patients in the post-SDP group were included in the study. SDP use increased significantly from 9% to 74% after implementation. In comparison with the pre-SDP group, both PDRs (44.1%-49.5%; P < .001) and ADRs (26.7%-31.8%; P < .001) significantly improved in the post-SDP group. The colonoscopy completion rate significantly increased from 93.6% to 95.5% in the post-SDP group (P = .008). Bowel preparation quality also improved significantly (P < .001) in the post-SDP group.nnnLIMITATIONSnRetrospective design; not all endoscopists were the same in both periods.nnnCONCLUSIONSnSystem-wide implementation of an SDP as the primary choice for colonoscopy significantly improved both PDRs and ADRs, overall quality of the preparation, and colonoscopy completion rates.

The water method significantly enhances patient-centered outcomes in sedated and unsedated colonoscopy.

Failure of cecal intubation when using air insufflation during scheduled unsedated colonoscopy in veterans prompted a literature search for a less uncomfortable approach. Water-related maneuvers as adjuncts to air insufflation were identified as effective in minimizing discomfort, although medication requirement was not reduced and willingness to repeat unsedated colonoscopy was not addressed. These adjunct maneuvers were combined with turning the air pump off to avoid colon elongation during insertion. Warm water infusion in lieu of air insufflation was evaluated in observational studies. Subsequent refinements evolved into the water method - a combination of air exclusion by aspiration of residual air to minimize angulations at flexures and a dynamic process of water exchange to remove feces in order to clear the view and aid insertion. In subsequent randomized controlled trials, the water method significantly reduced medication requirement, increased the proportion of patients in whom complete unsedated colonoscopy could be achieved, reduced patient recovery time burdens (sedation on demand), decreased abdominal discomfort during and after colonoscopy, enhanced cecal intubation, and increased willingness to repeat the procedure (scheduled unsedated). Supervised education of trainees and self-learning by an experienced colonoscopist were feasible. Lessons learned in developing the water method for optimizing patient-centered outcomes are presented. These proof-of-principle observations merit further research assessment in diverse settings.

Measurement of polypectomy rate by using administrative claims data with validation against the adenoma detection rate

BACKGROUNDnThe adenoma detection rate (ADR) is a main quality indicator in colonoscopy but has many challenges for calculating. The polypectomy rate (PR) may be calculable from administrative claims data, but this has not been validated against the ADR.nnnOBJECTIVEnTo determine whether a PR calculated from United States billing claims data is an accurate surrogate for the ADR.nnnDESIGNnA PR was calculated by using billing claims data from Current Procedural Terminology codes. The ADR was calculated for each endoscopist by using an endoscopy report database to which the pathology report data had been added. The relationship between PR and ADR was evaluated with the Pearson correlation coefficient. The ADR was plotted against the PR by individual endoscopist, and a least-squares regression line was created. A t test was used to analyze the differences in lesion detection between endoscopists with a PR above and below the benchmark PR.nnnSETTINGnTertiary-care, outpatient endoscopy center.nnnPATIENTSnAll ages undergoing colonoscopy.nnnMAIN OUTCOME MEASUREMENTSnPR and ADR.nnnRESULTSnA total of 5382 colonoscopies were reviewed. A significant relationship between endoscopists calculated PRs and ADRs was seen (r = 0.85; P < .001). Endoscopists needed a PR of 35% to achieve the recommended benchmark ADR of 20%. Endoscopists with PRs of 35% or greater had an ADR of 27% (6.2 standard deviation [SD]) as compared with 19% (1.9 SD) for those with PRs less than 35% (P = .0029).nnnLIMITATIONSnStudy population.nnnCONCLUSIONnCalculated PR from billing claims data is an accurate surrogate for ADR and may become an important quality measure for external and internal use.

Barrett's esophagus: endoscopic diagnosis.

This collection of summaries on endoscopic diagnosis of Barretts esophagus (BE) includes the best endoscopic markers of the extent of BE; the interpretation of the diagnosis of ultra‐short BE; the criteria for endoscopic grading; the sensitivity and specificity of endoscopic diagnosis; capsule and magnifying endoscopy; narrow band imaging; balloon cytology; the distinction between focal and diffuse dysplasia; the techniques for endoscopic detection of dysplasia and the grading systems; and the difficulty of interpretation of inflammatory or regenerative changes.

Impact of fentanyl in lieu of meperidine on endoscopy unit efficiency: a prospective comparative study in patients undergoing EGD

BACKGROUNDnTurnaround time is an important component of endoscopy unit efficiency. Any reduction in the total time from patient arrival in the endoscopy room to departure from the recovery area may translate into better endoscopy unit efficiency.nnnOBJECTIVEnTo evaluate the effects on endoscopy unit efficiency of a change in narcotic choice for moderate sedation in patients undergoing EGD at an ambulatory surgery center.nnnDESIGNnProspective, comparative, quality-improvement project.nnnSETTINGnEndoscopy unit of a tertiary-care academic medical center.nnnPATIENTSnWe enrolled consecutive patients (n = 1963) who underwent outpatient EGD by 1 of 5 endoscopists between November 2008 and November 2010.nnnINTERVENTIONnModerate sedation with midazolam plus fentanyl versus meperidine.nnnMAIN OUTCOME MEASUREMENTSnSedation-dependent endoscopy unit efficiency and total procedure time (induction-to-intubation, intubation-to-extubation, and extubation-to-discharge).nnnRESULTSnFentanyl was associated with reduced total procedure time by 10.1 minutes resulting from both shorter induction-to-intubation time and extubation-to-discharge time (P < .001). The mean (± SD) sedation-dependent endoscopy unit efficiency was 3.2 (± 1.9) procedures per hour for the meperidine group and 3.9 (± 2.7) procedures per hour for the fentanyl group (P = .012); this would translate into possibly increasing the endoscopy suite efficiency by 22%. Based on dosage equivalency conversion, equal doses of fentanyl and meperidine were used. No sedation-related complications or need for reversal agents were recorded.nnnLIMITATIONSnNo randomization was performed.nnnCONCLUSIONnCompared with meperidine, fentanyl in combination with midazolam was associated with significantly shorter total procedure time. By improving the turnaround time, sedation-dependent endoscopy unit efficiency may be improved by 22%.

Self-Dilation as a Treatment for Resistant, Benign Esophageal Strictures

Goals and BackgroundSimple benign strictures may be relieved with one to three dilation sessions. Resistant benign strictures are anatomically complex and resistant to therapy. We sought to determine the efficacy and safety of esophageal self-dilation with bougie dilators in the largest series to date.StudyA retrospective chart review was performed to identify patients who underwent esophageal self-dilation at two tertiary referral centers (Mayo Clinic, Scottsdale, Arizona and Mayo Clinic Rochester, Minnesota) between January 1, 2003 and June 30, 2012. Demographic details and clinical information regarding relief of dysphagia, complications, and frequency of endoscopic and self-dilation were abstracted.ResultsOf the 32 patients who began self-dilation for nonmalignant strictures, 30 [22 men; median (range) age, 62xa0years (22–86xa0years)] were included in the study. Median (range) follow-up was 37xa0months (14–281xa0months). Stricture etiology included radiation therapy (nxa0=xa08), anastomotic stricture (nxa0=xa09), eosinophilic esophagitis (nxa0=xa04), caustic ingestion (nxa0=xa03), photodynamic therapy (nxa0=xa02), granulation tissue (nxa0=xa02), peptic stricture (nxa0=xa01) and one patient had radiation therapy and peptic stricture. The average number (range) of physician performed dilations before self-dilation was 12 (4–55). Esophageal self-dilation was successful in treating 90xa0% of patients. Dysphagia score (2 vs. 1; Pxa0<xa00.001), stricture diameter (median; 5 vs. 12xa0mm; Pxa0<xa00.001) and weight (median; 73 vs. 77xa0kg; Pxa0<xa00.001) were significantly different between EDG dilation versus self-dilation.ConclusionsEsophageal self-dilation is a safe, effective treatment for resistant, benign esophageal strictures. This management strategy should be strongly considered in this patient population.

Characterization of right wrist posture during simulated colonoscopy: an application of kinematic analysis to the study of endoscopic maneuvers

BACKGROUNDnEndoscopic maneuvers are associated with a high incidence of musculoskeletal injuries.nnnOBJECTIVEnTo quantify wrist motion patterns during simulated endoscopic procedures to identify potential causes of endoscopy-related overuse injury.nnnDESIGNnTwelve endoscopists with different levels of experience were tested on 2 simulated endoscopic procedures that differed in their level of difficulty.nnnSETTINGnRight wrist movement patterns were recorded during simulated colonoscopies by using a magnetic motion-tracking device. Analysis focused on 3 wrist degrees of freedom: abduction/adduction, flexion/extension, and pronation/supination.nnnINTERVENTIONSnSubjects were tested on 2 GI lower endoscopies (colonoscopies) on a simulator.nnnMAIN OUTCOME MEASUREMENTSnTime spent within ranges of the entire wrist range of motion for 3 wrist degrees of freedom.nnnRESULTSnEndoscopists spent up to 30% of the duration of the procedures at the extremes of the wrist joint range of motion. Endoscopic experience did not affect the time spent at the extremes of the wrist joint of motion. The time spent within each range of motion differed depending on the wrist degrees of freedom and difficulty of procedure.nnnLIMITATIONSnThis study examined only 1 upper limb joint in a limited number of subjects and did not measure interaction forces with endoscopic tools.nnnCONCLUSIONSnWe identified wrist movement patterns that can potentially contribute to the occurrence of musculoskeletal injury in endoscopists. This study lays the foundation for future work on establishing links between upper limb movement patterns and the occurrence of overuse injury caused by repetitive performance of endoscopic procedures.

Prevalence of buried Barrett's metaplasia in patients before and after radiofrequency ablation.

BACKGROUND AND STUDY AIMnRadiofrequency ablation (RFA) to treat Barretts esophagus is increasingly accepted. Description of the etiology, natural history, and prevalence of buried Barretts metaplasia (BBM) following RFA is limited, although BBM continues to pose a clinical dilemma. We aimed to assess the prevalence, characteristics, and eradication rate of BBM in patients with both dysplastic and nondysplastic Barretts esophagus, treated with RFA and followed over time.nnnPATIENTS AND METHODSnThe presence of Barretts esophagus, dysplasia, and BBM, before and after RFA, was assessed by two gastrointestinal pathologists in a retrospective chart review of patients who had undergone RFA at our center and had completed appropriate follow-up.nnnRESULTSnWe identified 112 patients with completed treatment and no further planned RFA. In 108, no residual Barretts esophagus was seen after RFA; 4 patients with persistent Barretts tissue underwent surgery. Regarding BBM, 17/112 patients (15.2%) had evidence of BBM during evaluation. In 12/17 (70.5%) BBM was found during the RFA treatment, with 8 having previously undergone non-RFA therapy and RFA for Barretts esophagus and 4 having no previous intervention. In 5/17 (29.4%), BBM was seen only after RFA monotherapy. All 17 showed no evidence of BBM at final evaluation and were classified in the complete remission group (108/112).nnnCONCLUSIONnBoth Barretts esophagus and BBM were completely eradicated in all patients with long-term follow-up after RFA. Almost half of the patients with BBM had a prior history of non-RFA therapy for Barretts esophagus compared with 26% the non-BBM cohort. All patients with previously identified Barretts esophagus and BBM were completely cleared of disease at final follow-up.