Johannes Wilhelm Rey

Intraprocedural bowel cleansing with the JetPrep cleansing system improves adenoma detection

AIMnTo investigate the impact of JetPrep cleansing on adenoma detection rates.nnnMETHODSnIn this prospective, randomized, crossover trial, patients were blindly randomized to an intervention arm or a control arm. In accordance with the risk profile for the development of colorectal carcinoma, the study participants were divided into high-risk and low-risk groups. Individuals with just one criterion (age > 70 years, adenoma in medical history, and first-degree relative with colorectal cancer) were regarded as high-risk patients. Bowel preparation was performed in a standardized manner one day before the procedure. Participants in the intervention arm underwent an initial colonoscopy with standard bowel cleansing using a 250-mL syringe followed by a second colonoscopy that included irrigation by the use of the JetPrep cleansing system. The reverse sequence was used in the control arm. The study participants were divided into a high-risk group and a low-risk group according to their respective risk profiles for the development of colorectal carcinoma.nnnRESULTSnA total of 64 patients (34 men and 30 women) were included in the study; 22 were included in the high-risk group. After randomization, 30 patients were assigned to the control group (group A) and 34 to the intervention group (group B). The average Boston Bowel Preparation Scale score was 5.15 ± 2.04. The withdrawal time needed for the first step was significantly longer in group A using the JetPrep system (9.41 ± 3.34 min) compared to group B (7.5 ± 1.92 min). A total of 163 polyps were discovered in 64 study participants who underwent both investigation steps. In group A, 49.4% of the polyps were detected during the step of standard bowel cleansing while the miss rate constituted 50.7%. Group B underwent cleansing with the JetPrep system during the first examination step, and as many as 73.9% of polyps were identified during this step. Thus, the miss rate in group B was a mere 26.1% (P < 0.001). When considering only the right side of the colon, the miss rate in group A during the first examination was 60.6%, in contrast to a miss rate of 26.4% in group B (P < 0.001).nnnCONCLUSIONnJetPrep is recommended for use during colonoscopy because a better prepared bowel enables a better adenoma detection, particularly in the proximal colon.

A guide to multimodal endoscopy imaging for gastrointestinal malignancy [mdash] an early indicator

Multimodality imaging is an essential aspect of endoscopic surveillance for the detection of neoplastic lesions, such as dysplasia or intramucosal cancer, because it improves the efficacy of endoscopic surveillance and therapeutic procedures in the gastrointestinal tract. This approach reveals mucosal abnormalities that cannot be detected by standard endoscopy. Currently, these imaging techniques are divided into those for primary detection and those for targeted imaging and characterization, the latter being used to visualize areas of interest in detail and permit histological evaluation. This Review outlines the use of virtual chromoendoscopy, narrow-band imaging, autofluorescence imaging, optical coherence tomography, confocal endomicroscopy and volumetric laser endomicroscopy as new imaging techniques for diagnostic investigation of the gastrointestinal tract. Insights into use of multimodal endoscopic imaging for early disease detection, in particular for pre-malignant lesions, in the oesophagus, stomach and colon are described.

The Manchester Triage System (MTS): a score for emergency management of patients with acute gastrointestinal bleeding

BACKGROUNDnu2002Suspected gastrointestinal (GI) bleeding is a common initial diagnosis in emergency departments. Despite existing endoscopic scores to estimate the risk of GI bleeding, the primary clinical assessment of urgency can remain challenging. The 5-step Manchester Triage System (MTS) is a validated score that is often applied for the initial assessment of patients presenting in emergency departments.nnnMETHODSnu2002All computer-based records of patients who were admitted between January 2014 and December 2014 to our emergency department in a tertiary referral hospital were analyzed retrospectively. The aim of our retrospective analysis was to determine if patient triage using the MTS is associated with rates of endoscopy and with presence of active GI bleeding.nnnRESULTSnu2002In summary, 5689 patients with a GI condition were treated at our emergency department. Two hundred eighty-four patients (4.9u200a%) presented with suspected GI bleeding, and 165 patients (58u200a%) received endoscopic diagnostic. Endoscopic intervention for hemostasis was needed in 34 patients (21u200a%). In patients who underwent emergency endoscopy, triage into MTS categories with higher urgency was associated with higher rates of endoscopic confirmation ofxa0suspected GI bleeding (79u200a% of patients with MTS priority levels 1 or 2, 53u200a% in level 3 patients, and 40u200a% in levels 4 or 5 patients; pu200a=u200a0.024).nnnCONCLUSIONSnu2002The MTS is an established tool for triage in emergency departments and could have a potential to guide early clinical decision-making with regards to urgency of endoscopic evaluation in patients with suspected GI bleeding.

Endoscopic Bleeding Control

Gastrointestinal bleeding (GIB) can occur at different locations and different intensities throughout the intestine. Gastrointestinal bleeding is subdivided based on the location (upper, lower, middle GIB). The upper GI tract comprises the esophagus, stomach, and duodenum (up to the papilla of Vateri). Middle GIB relates to that part of the GI tract located below the papilla Vateri up to the terminal ileum. Lower GIB is defined as a bleeding within the colon and rectum.

PTH-008 Outcomes from an international multicentre hemospray registry

Introduction Acute gastrointestinal bleeding (AGIB) carries poor outcomes unless prompt endoscopic haemostasis is achieved. Hemospray is a novel intervention that creates a mechanical barrier over bleeding sites when applied endoscopically. Primary aim of this international prospective multicentre registry is to collect outcomes of patients with AGIB after endoscopic Hemospary application. Secondary outcomes of rebleeding, disease and procedure specific outcomes are also collected. Method Prospective data (Jan2016-Jan2018) from 11 centres across UK, France and Germany collected. Hemospray used as mono therapy, dual-therapy with standard haemostatic techniques or rescue therapy once standard methods failed. Immediate haemostasis defined as cessation of bleeding within 5u2009min after application of Hemospray. Rebleeding defined as subsequent drop in Hb (>2u2009g/L), haematemesis, persistent melaena with haemodynamic compromise post therapy. Results 275 cases recruited worldwide(203 M and 72 F). Median pretreatment Blatchford score (BS) 11 for all cases. 246 patients (89%) achieved immediate haemostasis after endoscopic therapy with Hemospray (table 1). Similar haemostasis rates noted in the Hemospray monotherapy (92 %), combination therapy (90 %) and rescue therapy (85 %) group. Peptic ulcer bleed was the most common pathology (53%) and forrest Ib the most common lesion type (66%). 29 patients did not achieve immediate haemostasis.Median BS was higher in this group at 13 (IQR 11–16, p<0.05). Forrest Ib was the most common lesion type in this group (76%, p<0.05). 28 cases of rebleeding reported after successful haemostasis. The median BS in these was higher at 13 (IQR 10.25–14.75, p<0.05). Forrest Ib was the most common bleed in this group (50%, p<0.05).Abstract PTH-008 Figure 1 Conclusion These data show high rates of immediate haemostasis (89%). Forrest Type 1b lesions have a higher rate of unsuccessful haemostais and increased risk of rebleeding after therapy. Patients with rebleeding and unsuccessful treatment had higher BS at baseline. The expansion of this international registry will provide data on the efficacy of Hemospray in various disease and patient types over the coming years.

G-EYE colonoscopy is superior to standard colonoscopy for increasing adenoma detection rate: an international randomized controlled trial (with videos)

BACKGROUND AND AIMSnColorectal cancer (CRC) is largely preventable with routine screening and surveillance colonoscopy; however, interval cancers arising from precancerous lesions missed by standard colonoscopy still occur. An increased adenoma detection rate (ADR) has been found to be inversely associated with interval cancers. The G-EYE device includes a reusable balloon integrated at the distal tip of a standard colonoscope, which flattens haustral folds, centralizes the colonoscopes optics, and reduces bowel slippage. The insufflated balloon also aims to enhance visualization of the colon during withdrawal, thereby increasing the ADR.nnnMETHODSnIn this randomized, controlled, international, multicenter study (11 centers), patients (agedxa0≥50 years) referred to colonoscopy for screening, surveillance, or changes in bowel habits were randomized to undergo either balloon-assisted colonoscopy by using an insufflated balloon during withdrawal or standard high-definition colonoscopy. The primary endpoint was the ADR.nnnRESULTSnOne thousand patients were enrolled between May 2014 and September 2016 to undergo colonoscopy by experienced endoscopists; 803 were finally analyzed (standard colonoscopy nxa0= 396; balloon-assisted colonoscopy nxa0= 407). Baseline parameters were similar in both groups. Balloon-assisted colonoscopy provided a 48.0% ADR compared with 37.5% in the standard colonoscopy group (28% increase; Pxa0= .0027). Additionally, balloon-assisted colonoscopy provided for a significant increase in detection of advanced (Pxa0= .0033) flat adenomas (Pxa0<xa0.0001) and sessile serrated adenomas/polyps (Pxa0= .0026).nnnCONCLUSIONnBalloon-assisted colonoscopy yielded a higher ADR and increased the detection of advanced, flat, and sessile serrated adenomas/polyps when compared with standard colonoscopy. Improved detection by the G-EYE device could impact the quality of CRC screening by reducing miss rates and consequently reducing interval cancer incidence. (Clinical trial registration number: NCT01917513.).

The Near Future of Endoscopic Screening in IBD

Patients with long-standing extensive chronic inflammatory bowel disease (IBD) have an increased risk of developing intraepithelial neoplasia and colitis-associated cancer (CAC) compared to the average risk population. In 2003, the first randomized, controlled trial was published evaluating lesions in the colon according to a modified Pit-Pattern classification after pan-chromoendoscopy with methylene blue (0.1 %). Chromoendoscopy enabled unmasking dysplastic lesions and clarifying the borders between neoplastic and normal tissue. This has led to the “smart biopsy” concept, where more targeted biopsies become possible after enhanced endoscopy (chromoendoscopy). In addition, confocal laser endomicroscopy (CLE) has revealed in vivo tissue changes in vessel, connective tissue and cellular-subcellular structures.