Jean François Rey

Pragmatic classification of superficial neoplastic colorectal lesions

Recently, the emerging role of nonpolypoid precursors of colorectal cancer has challenged the conventional polyp-cancer sequence. The impact of colonoscopy in cancer prevention depends on its reliability in the diagnosis of colorectal neoplasia when the lesion does not extend beyond the submucosa and is potentially curable. The estimation of the risk of progression is based on the prediction of histology from the morphological appearance of the lesion and includes (1) distinction between neoplastic and non-neoplastic lesions, (2) identification of different categories of non-serrated and serrated lesions, and (3) determination of the localization in the proximal or distal colon, which has an impact on the morphology and behavior of the lesion. The pragmatic classification Of superficial neoplastic lesions proposed in this text takes into account these changes and is based oil a 2-step strategy of endoscopic diagnosis with initial detection and characterization, followed by treatment implementation, Such as endoscopic resection, ablation, and Surgery

Blinded nonrandomized comparative study of gastric examination with a magnetically guided capsule endoscope and standard videoendoscope

BACKGROUND Passive video capsule endoscopy is the criterion standard for small-bowel exploration but cannot be used for the large gastric cavity. We report the first blinded comparative clinical trial in humans comparing a magnetically guided capsule endoscope (MGCE) and a conventional high-definition gastroscope. OBJECTIVE To assess the potential of gastric examination with a guided capsule. DESIGN Blinded, nonrandomized comparative study. SETTING Single endoscopy center. METHODS The trial involved 61 patients included in a blinded capsule and gastroscopy comparative study. MGCE examination was performed 24 hours after patients had undergone gastroscopy. To remove food residue or mucus, patients drank 900 mL of water in 2 portions. Then to provide the air-water interface required by the guidance system, they drank 400 mL of water at 35°C. RESULTS Visualization of the gastric pylorus, antrum, body, fundus, and cardia was evaluated as complete in 88.5%, 86.9%, 93.4%, 85.2%, and 88.5% of patients, respectively. Of gastric lesions, 58.3% were detected by both gastroscopy and MGCE at immediate assessment and review of recorded data. Capsule examination missed 14 findings and gastroscopy missed 31 findings seen with MGCE. Overall diagnostic yield was similar for both modalities. LIMITATION Pilot study. CONCLUSIONS Diagnostic results were similar for the 2 methods. After some technical difficulties related to gastric expansion or presence of mucus had been overcome, this study opened a new field for noninvasive gastric examination in countries where high gastric cancer incidence demands a screening tool.

Magnetically guided capsule versus conventional gastroscopy for upper abdominal complaints: A prospective blinded study

Objectives: Upper gastrointestinal endoscopy is mostly performed under sedation and has a low yield of relevant gastric lesions in patients without alarm symptoms. Simpler screening tests such as capsule endoscopy could be helpful, but gastric visualization is insufficient with the current passive capsules. A magnetically guided gastric capsule was prospectively evaluated in patients with routine indications for gastroscopy. Methods: A total of 189 symptomatic patients (105 male; mean age 53 y) from 2 French centers subsequently and blindly underwent capsule and conventional gastroscopy by 9 and 6 examiners, respectively. The final gold standard was unblinded conventional gastroscopy with biopsy under propofol sedation. Main outcome was accuracy (sensitivity/specificity) of capsule gastroscopy for diagnosis of major gastric lesions, defined as those lesions requiring conventional gastroscopy for biopsy or removal. Results: Twenty-three major lesions were found in 21 patients. Capsule accuracy was 90.5% [95% confidence interval (CI), 85.4%-94.3%] with a specificity of 94.1% (95% CI, 89.3%-97.1%) and a sensitivity of 61.9% (95% CI, 38%-82%). Accuracy did not correlate with lesion location, gastric luminal visibility, examiner case volume, or examination time. Of the remaining 168 patients, 94% had minor and mostly multiple lesions; the capsule made a correct diagnosis in 88.1% (95% CI, 82.2%-92.6%), with gastric visibility and lesion location in the proximal stomach having significant influence. All patients preferred capsule gastroscopy. Conclusions: In a prospective and strictly blinded study, magnetically guided capsule gastroscopy was shown to be feasible in clinical practice and was clearly preferred by patients. Improvements in capsule technology may render this technique a future alternative to gastroscopy.

Role of enhanced visibility in evaluating polyposis syndromes using a newly developed contrast image capsule endoscope.

Background/Aims A flexible spectral imaging color enhancement system was installed in new capsule software for video capsule endoscopy. Contrast image capsule endoscopy (CICE) is a novel technology using light-emitting diodes selected for the main absorption range of hemoglobin. We assessed the feasibility and diagnostic effi cacy for small bowel surveillance in patients with polyposis syndromes. Methods Six patients with polyposis syndromes, four with familial adenomatous polyposis and one each with Cowden syndrome (CS) and Cronkhite-Canada syndrome (CCS) were examined using CICE. We conducted three evaluations to assess the effect on the numbers of the detected polyps; compare polyp diagnostic rates between adenoma and hamartoma; and assess polyp visibility. Results The numbers of detected polyps and diagnostic accuracy did not differ signifi cantly between pre-contrast and contrast images. However, 50% of the adenomatous polyps displayed enhanced visibility on contrast images. CICE contrast images exhibited clearly demarcated lesions and improved the visibility of minute structures of adenomatous polyps. Hamartomatous polyp micro-structures in patients with CS and CCS were more clearly visualized on contrast than pre-contrast images. Conclusions CICE is an effective tool for enhancing the visibility of polyps in patients with polyposis syndrome.

Appropriateness of Diagnostic Digestive Endoscopy

The indications of diagnostic endoscopy – upper gastrointestinal endoscopy or colonoscopy – in the exploration of the digestive tract are classified as appropriate or inappropriate with regard to criteria established in guidelines supported by national scientific societies and by insurance companies. This applies to the exploration of symptomatic patients and to screening protocols for malignant lesions. Functional or nonstructural diseases being more frequent than structural diseases, negative findings in endoscopy are common. However this reassures the patient and should not be considered as overuse. On the other hand excess in the repetition of negative endoscopic procedures during surveillance raises ethical problems, increased costs, and may be considered as unethical.

Infections et cholangio-pancreatographie rétrograde endoscopique (C.P.R.E.)

RésuméLe cathétérisme rétrograde endoscopique des voies biliaires et pancréatiques, avec ses possibilités diagnostiques et thérapeutiques est une méthode largement utilisée. Nous avons voulu faire le point sur la fréquence et la prévention de ses complications infectieuses qui reste un facteur limitant de cette méthode.L’étude de la littérature permet de constater une nette diminution de la mortalité (0,1 %) et de la morbidité (0,8 %) de cette technique. Les complications infectieuses apparaissent désormais au premier plan des manifestations cliniques. Le mode de contamination peut étre endogène, lié au malade, ou exogène, au niveau de l’endoscope; les conditions locales liées à un obstacle biliaire ou à un kyste pancréatique peuvent faciliter le développement d’une manifestation infectieuse.Si l’expérience de l’opérateur, le traitement immédiat de la stase ou dans certains cas, une antibiothérapie prophylactique, peuvent être utiles, ce sont les méthodes de décontamination du matériel qui doivent permettre de diminuer le nombre de ces infections iatrogènes.SummaryEndoscopic retrograde cholangiopancreatography (E.R.C.P.) with its diagnostic and therapeutic possibilities is a well established method. We wanted to take a bearing of the frequency and the prevention of its infectious complications which are the weak point of this method. A study of the literature highlights a clear decrease in mortality (0,1 %) and morbidity (0,8 %) concerning this technique. From now on these infectious complications appear in the foreground of clinical expressions. The pathway of contamination can be endogenous linked to the patient or exogenous and linked to the endoscope. The pathological conditions such as biliary stenosis or pancreatic cyst may induce the development of an infectious expression. The operator’s experience, the immediate treatment of the stasis or in some cases a prophylactic antibiotictherapy can all be useful. However, decontamination of the material is most manner to decrease number of iatrogen infection.

T2A — CCAM: risques ou chances pour les hépato-gastroentérologues

La reforme de la T2A ou plus exactement de la tarification a l’activite va etre mise en place dans les etablissements de soins prives parallelement a la Classification Commune des Actes Medicaux ou CCAM . Ces deux reformes ont ete imaginees simultanement mais developpees d’une maniere relativement opaques, non cooperatives. Ceci est du au fait que, pour leur part liberale, les hepato-gastroenterologues sont sous la responsabilite tarifaire des Caisses d’Assurance Maladie alors que les etablissements de soins prives, comme les etablissements de soins publics, sont sous la responsabilite tarifaire de la Direction de l’Hospitalisation et de l’Organisation des Soins ou DHOS. Bien sur ces deux Administrations se cotoient mais communiquent peu, meme si paradoxalement, le Docteur Martine Aoustin a exerce, pendant de tres nombreuses annees, des responsabilites au niveau de l’echelon national du controle medical de la CNAMTS.

La décontamination du matériel endoscopique

ConclusionLa décontamination du matériel endoscopique fait partie intégrante de la qualité des soins due aux patients. Pour gage de son efficacité, la éthodologie proposée, qui repose sur l’expérience de nombreux auteurs anglo-saxons, nécessite du personnel compétent et entraÎné.