Madhusudhan R. Sanaka

Adenomas Are Detected More Often in Morning Than in Afternoon Colonoscopy

OBJECTIVES:The effectiveness of colonoscopy in preventing colon cancer depends on adenoma detection and removal. Adequacy of bowel preparation, careful mucosal visualization, and adequate withdrawal time are known to affect adenoma detection rate (ADR). Physician fatigue, which usually increases as the day progresses, might impair ADR. The aim of this study is to assess the effect of timing of colonoscopy, morning vs. afternoon, on ADR.METHODS:Medical records of 9,063 colonoscopies performed in 2006 were reviewed for patient demographics, indications, timing, and findings of colonoscopy. Asymptomatic outpatients who had adequate bowel preparation and complete colonoscopy were included. Morning colonoscopies were defined as those that started before 12 noon and afternoon colonoscopies as those that started after 12 noon. ADR is defined as the detection of at least one adenoma per colonoscopy.RESULTS:A total of 3,619 colonoscopies were included, of which 1,748 (48.3%) were done in the morning and 1,871 (51.7%) were done in the afternoon. ADR was 29.3% in the morning group compared with 25.3% in the afternoon group (P=0.008). There was a trend toward declining ADR for each subsequent hour of the day (P=0.01). In multivariable analysis, colonoscopy in the morning was significantly associated with increased ADR (odds ratio (OR) 1.2 (1.06, 1.4) P=0.006).CONCLUSIONS:Time of performance of colonoscopy seems to be an independent predictor for adenoma detection. ADR was significantly higher in morning colonoscopies than in afternoon colonoscopies. The reasons and implications of this finding should be studied further.

The Clinical Utility of Single Balloon Enteroscopy: A Single Center Experience of 172 Procedures

BACKGROUND Single-balloon enteroscopy (SBE) is a novel endoscopic technique designed to evaluate and treat small-bowel disease. Although there is substantial literature addressing double-balloon enteroscopy and its impact on the diagnosis and management of small-bowel disease, there are limited data available on the clinical utility of SBE. OBJECTIVES To evaluate the clinical utility and diagnostic impact of SBE in a large cohort of patients at a single tertiary center. DESIGN Single-center, retrospective study. SETTING Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio. PATIENTS A total of 161 patients were referred for SBE from January 2006 to August 2008. MAIN OUTCOME MEASUREMENTS Demographic, clinical, procedural, and outcome data were collected and analyzed. RESULTS A total of 161 patients underwent a total of 172 procedures. Antegrade and retrograde approaches were used in 83% and 17% of subjects, respectively. The average insertion depth using the antegrade approach was 132 cm beyond the ligament of Treitz (range 20-400 cm). The average insertion depth using the retrograde approach was 73 cm above the ileocecal valve (range 10-160 cm). The average procedure time was 40 minutes overall, 38 minutes (range 12-90) antegrade and 48 minutes (range 28-89) retrograde. Fluoroscopy was used in 20 cases (12%). Diagnostic yield was 58% (99/172); 42% (72/172) were therapeutic cases. There were no significant complications. LIMITATIONS Single-center, retrospective study. CONCLUSIONS SBE demonstrated a high diagnostic yield and frequently provided useful therapeutic intervention. It seems to be a safe and effective method for performing deep enteroscopy.

Antegrade Is More Effective Than Retrograde Enteroscopy for Evaluation and Management of Suspected Small-Bowel Disease

BACKGROUND & AIMS Antegrade and retrograde enteroscopy are useful for evaluating the proximal and distal small bowel, respectively. We compared the diagnostic yield, therapeutic yield, and complications of antegrade and retrograde enteroscopy. METHODS We performed a retrospective review of a prospectively maintained database of patients who underwent small-bowel enteroscopy at our institution from January 2008 to August 2009. All enteroscopies were performed using single-balloon enteroscopy (SBE), double-balloon enteroscopy (DBE), or spiral enteroscopy (SE). A total of 250 enteroscopies were performed; 182 were antegrade (91 SBE, 52 DBE, and 39 SE) and 68 were retrograde (23 SBE, 37 DBE, and 8 SE). The mean age of the patients was 61.5 ± 15.8 years. RESULTS The most common indication for small-bowel endoscopy was obscure gastrointestinal bleeding (n = 83). The diagnostic yield was significantly higher for antegrade than retrograde enteroscopy (63.7% vs 39.7%; P < .001). Antegrade procedures were of shorter duration than retrograde enteroscopy (44.3 ± 22.0 vs 58.9 ± 29.7 min; P < .001), and the mean depth of maximal insertion was significantly greater with antegrade endoscopy (231.8 ± 122.1 vs 103.4 ± 102.8 cm; P < .001). The therapeutic yield also was significantly higher for anterograde enteroscopy than retrograde enteroscopy (55.5% vs 44.1%; P < .001). There were no significant differences in complications. CONCLUSIONS Antegrade enteroscopy appears to provide a higher diagnostic and therapeutic yield than retrograde enteroscopy in patients with suspected small-bowel disease.

Similar Risk of Cardiopulmonary Adverse Events Between Propofol and Traditional Anesthesia for Gastrointestinal Endoscopy: A Systematic Review and Meta-analysis

BACKGROUND & AIMS: Even though propofol use for gastrointestinal endoscopic procedures has increased over the past decade, there is a perception that it causes a higher rate of cardiopulmonary adverse events. The aim of this study was to compare the sedation‐related adverse events associated with use of propofol vs nonpropofol agents for endoscopic procedures. We also wanted to determine the influence of duration or complexity of the procedures and endoscopist‐directed (gastroenterologist) vs non–gastroenterologist‐directed sedation on the outcomes. METHODS: A search was conducted using Medline, EMBASE, and the Cochrane controlled trials registry. The following cardiopulmonary adverse events were assessed: hypoxia, hypotension, and arrhythmias. The procedures were divided into 2 groups based on the procedure length: a nonadvanced endoscopic procedure group consisting of esophagogastroduodenoscopy, colonoscopy, and sigmoidoscopy, and an advanced endoscopic procedures group including endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, balloon enteroscopy, and endoscopic submucosal dissection. Pooled odds ratios for complications were calculated for all the procedures combined and then separately for the 2 groups. Random‐effects models were used for 2‐proportion comparisons. RESULTS: Of the 2117 citations identified, 27 original studies qualified for this meta‐analysis and included 2518 patients. Of these, 1324 received propofol, and 1194 received midazolam, meperidine, pethidine, remifentanil, and/or fentanyl. Most of the included studies were randomized trials of moderate quality and nonsignificant heterogeneity (Cochran Q, 26.07; P = .13). Compared with traditional sedative agents, the pooled odds ratio with the use of propofol for developing hypoxia for all the procedures combined was 0.82 (95% confidence interval [CI], 0.63–1.07), and for developing hypotension was 0.92 (95% CI, 0.64–1.32). In the nonadvanced endoscopic procedure group, those who received propofol were 39% less likely to develop complications than those receiving traditional sedative agents (odds ratio, 0.61; 95% CI, 0.38–0.99). There was no difference in the complication rate for the advanced endoscopic procedure group (odds ratio, 0.86; 95% CI, 0.56–1.34). A subgroup analysis did not show any difference in adverse events when propofol was administered by gastroenterologists or nongastroenterologists. CONCLUSIONS: Propofol sedation has a similar risk of cardiopulmonary adverse events compared with traditional agents for gastrointestinal endoscopic procedures. Propofol use in simple endoscopic procedures was associated with a decreased number of complications. When used for gastrointestinal endoscopic procedures of a complex nature and longer duration, propofol was not associated with increased rates of hypoxemia, hypotension, or arrhythmias. Administration of propofol by gastroenterologists does not appear to increase the complication rates.

Lipidomic profiling of bile in distinguishing benign from malignant biliary strictures: a single-blinded pilot study.

OBJECTIVES:Ascertaining the benign or malignant nature of biliary strictures may be challenging. Oxidized phospholipids (oxPLs) play an important role in tumor apoptosis and may be elevated in malignant biliary strictures. The objective of the study was to investigate whether oxPLs are enriched in the bile of malignant biliary strictures.METHODS:In this prospective single-blinded study, bile was obtained from 46 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis and management of biliary strictures, including 17 with pancreatic cancer, 6 with primary sclerosing cholangitis (PSC), 8 with cholangiocarcinoma (CCA), and 15 with benign biliary conditions (sphincter of Oddi dysfunction (SOD) or choledocholithiasis or chronic pancreatitis). Bile samples were stored under conditions to minimize artificial oxidation. Levels of 10 different oxPLs were measured blindly by one investigator using liquid chromatography electrospray ionization tandem mass spectrometry (LC-ESI-MS/MS).RESULTS:Of the 10 different phospholipids measured, the levels of two phosphatidylcholines (PCs; i.e., ON-PC and S-PC) were elevated in CCA as compared with other biliary strictures. Among these, ON-PC was most useful and a cutoff value of 6,020.1 nm distinguished CCA from other biliary strictures with a sensitivity and specificity of 85.7% and 80.3%, respectively (area under curve (AUC) 0.86). A combination of ON-PC and S-PC at a cutoff value of 6,032.2 nm distinguished CCA from other biliary strictures with a sensitivity and specificity of (100% and 83.3%, respectively (AUC 0.91).CONCLUSIONS:The measurement of specific oxPL products may help to distinguish CCA from other biliary strictures. Measurement of these products in bile may enhance the endoscopic diagnosis of indeterminate biliary strictures.

Endoscopic ultrasound in the diagnosis of cholangiocarcinoma as the etiology of biliary strictures: a systematic review and meta-analysis

Background and aim: Extrahepatic cholangiocarcinoma (CCA) typically presents as biliary strictures. Endoscopic ultrasound (EUS)-fine needle aspiration (FNA) may contribute to the diagnosis of CCA as the etiology of extrahepatic biliary strictures. Our aim was to study the uselfulness of EUS-FNA in diagnosing CCA as the etiology of biliary strictures. Patients and methods: In this meta-analysis, PUBMED and EMBASE databases were examined to find studies published to April 2014 where diagnostic correlation of CCA was available. Studies reporting only “positive for malignancy” were included in our analysis. The main outcome measurements were sensitivity, specificity and likelihood ratio. Results: Six studies were included, covering 196 patients. The overall pooled sensitivity and negative likelihood ratio (LR-) of EUS-FNA for diagnosis of CCA were 66% [95% confidence interval (CI) 57–74%] and 0.34 (95% CI 0.26–0.43), respectively. In five studies (146 patients), where a mass lesion was detected during EUS, the pooled sensitivity and LR- of EUS-FNA for diagnosis of CCA were 80% [95% CI 72–87%] and 0.20 (95% CI 0.13–0.28), respectively. In the 49 patients with a negative brush cytology, the pooled sensitivity and LR- of EUS-FNA for diagnosis of CCA were 59% [95% CI 44–73%] and 0.41 (95% CI 0.27–0.56), respectively. Conclusions: Our study suggests that EUS-FNA is useful in the evaluation of CCA as the etiology of biliary strictures. EUS-FNA may improve the diagnosis of CCA in patients with negative cytology and no mass on cross-sectional imaging.

Natural history of low grade dysplasia in patients with primary sclerosing cholangitis and ulcerative colitis

BACKGROUND AND AIM Patients with ulcerative colitis (UC) and primary sclerosing cholangitis (PSC) are at increased risk of colon cancer. The aim of this study was to determine the natural history of LGD and its progression to high grade dysplasia (HGD)/colorectal cancer (CRC) in PSC-UC patients. METHODS Ten PSC-UC patients with LGD who underwent surveillance colonoscopy from 1996 to 2011 were evaluated. Raised dysplasia was defined as a discrete raised lesion located in an area involved by either quiescent or active colitis that was endoscopically resected, while flat dysplasia was defined as the absence of documentation of a raised lesion. RESULTS Of the 10 patients with LGD, 3 (30%) progressed to raised HGD over a mean follow-up of 13±11 months. Three of 10 patients had initial raised LGD while 7 had flat LGD. The location of HGD was in the proximal colon in all 3 patients. However all 3 patients who progressed to HGD had initial dysplasia located in the distal colon and had flat morphology. The incidence rate for detection of HGD/CRC was 9.4 cases per 100 person years at risk. Patients with LGD with flat morphology had an incidence rate of 17.8 cases per 100 person years at risk. HGD occurred more frequently within the first year of initial detection of LGD (23.5 per 100 patient years of follow-up). CONCLUSIONS One-third of patients with LGD progressed to HGD/CRC in PSC-UC. Most patients progress within the first year of diagnosis of LGD supporting early colectomy in PSC-UC patients with LGD.

Delay in performing ERCP and adverse events increase the 30-day readmission risk in patients with acute cholangitis

BACKGROUND Readmission to the hospital within 30 days of discharge (30-day readmission rate) is used as a quality measure. OBJECTIVE To investigate the incidence and factors that contribute to readmissions in patients with acute cholangitis. DESIGN Retrospective cohort study. SETTING Tertiary-care referral center. PATIENTS Retrospective analysis of consecutive patients admitted to our center for acute cholangitis and ERCP. INTERVENTION ERCP MAIN OUTCOME MEASUREMENTS Incidence and variables associated with 30-day readmission and 1-year mortality. RESULTS ERCP was successful in 98.8% of patients during the index admission. The 30-day readmission rate was 22.0%. Recurrence of cholangitis was the most common etiology for readmissions (37.8%). Readmission within 30 days was independently associated with failed ERCP or ERCP delayed for >48 hours (odds ratio [OR] 2.47; 95% confidence interval [CI], 1.01-6.07), development of any after-ERCP adverse event (OR 11.0; 95% CI, 3.06-39.30), and the etiology of cholangitis (etiologies not related to stones) (OR 3.3; 95% CI, 1.17-9.18). Every 1-point increase in the Charlson Comorbidity Index score (OR, 1.33; 95% CI, 1.05-1.69) was associated significantly with 1-year mortality. In unadjusted analysis, 30-day readmission after ERCP was associated significantly with 1-year mortality (OR, 2.86; 95% CI, 1.16-7.07). This association, however, was not present after adjustment for other covariates. LIMITATIONS Retrospective study. CONCLUSION Delays in performing ERCP during the index admission, development of after-ERCP adverse events, and etiology of cholangitis not related to stones increased the risk of 30-day readmissions.

ERCP-related adverse events in patients with primary sclerosing cholangitis.

BACKGROUND ERCP is frequently used in patients with primary sclerosing cholangitis (PSC) for cancer surveillance and treatment of dominant strictures. OBJECTIVE To evaluate the prevalence and risk factors for ERCP-related adverse events in patients with PSC. DESIGN Retrospective analysis of ERCPs performed from 1998 to 2012. SETTING Referral center. PATIENTS A total of 294 consecutive patients with PSC who underwent a total of 657 ERCPs. INTERVENTIONS ERCP. MAIN OUTCOME MEASUREMENTS ERCP-related adverse events and predictive factors were determined by univariate and multivariate analyses. RESULTS ERCP use in patients with PSC showed a significant increase during the second half of the study period (2006-2012) compared with the first half (1998-2005) (437 vs 220 procedures; P = .04). Primary cannulation was successful in 634 procedures (96.6%) or in 271 of 294 patients (92.2%). Access to the bile duct was achieved with a needle-knife in 19 procedures (2.9%), whereas ERCP was unsuccessful in 4 of 657 procedures (0.6%), and successful percutaneous drainage was performed. Post-ERCP pancreatitis (PEP) was diagnosed in 8 (1.2%), cholangitis in 16 (2.4%), and bleeding in 4 (0.7%) procedures. Overall, risk of any adverse event was 28 of 657 (4.3%) procedures. On multivariate analysis, performing biliary sphincterotomy (odds ratio [OR] 5.04; 95% confidence interval [CI], 2.01-12.60; P = .001) and passage of a guidewire into the pancreatic duct (OR 4.54; 95% CI, 1.44-14.30; P = .010) were independently associated with an increased risk of any adverse event. LIMITATIONS Retrospective study. CONCLUSION Cholangitis appears to be the most common adverse event despite intraprocedural antibiotic use. There was a low risk of adverse events in patients with PSC undergoing ERCP.

Polypectomy Rate: A Surrogate for Adenoma Detection Rate Varies by Colon Segment, Gender, and Endoscopist

BACKGROUND & AIMS The adenoma detection rate (ADR) is an important measure of the quality of colonoscopy; it is associated with interval colorectal cancer and varies among sexes and locations. Recommended indicators of competence for colonoscopy include minimal ADRs >25% for average-risk men and >15% for women. These ADRs are rigorous, so polypectomy detection rate (PR) has been suggested as a surrogate. Colonoscopy is less effective in the proximal colon, where interval cancers are more likely to occur. We compared ADRs and PRs in different segments of colon and between sexes. METHODS We performed a cross-sectional review of findings from 2167 screening colonoscopies performed by 65 endoscopists on average-risk outpatients at the Cleveland Clinic, 2008-2009. We reviewed colonoscopy and pathology reports of randomly selected procedures (mean, 33 ± 16 procedures per endoscopist). We calculated PRs, ADRs, and correlation between PR and ADR for each colon segment and sex. RESULTS The mean overall PR was 42% ± 16.7%, and ADR was 25% ± 3.3%. The correlation between overall ADR and PR was strong (r = 0.80). PR of 40% in men and 30% in women correlated with the established minimum benchmark ADRs of 25% and 15% for men and women, respectively. PR was more strongly correlated with ADR in the proximal colon (r = 0.92) than the distal colon (r = 0.58). The correlation was stronger in men than in women, as well as in the entire colon (r = 0.88 vs 0.75), the proximal colon (r = 0.91 vs 0.87), and the distal colon (r = 0.75 vs 0.55). The advanced ADR was 4% and did not correlate with PR (r = 0.32). CONCLUSIONS On the basis of a review of findings from screening colonoscopies, overall PR correlates with ADR for the entire colon, but PR and ADR correlate most strongly for the proximal colon, where many adenomas can be missed and interval cancers develop. The correlation between PR and ADR is weaker for women than men and for distal colon. If PR is used as a surrogate for ADR, colon location and patient sex should be considered.