Mark Pochapin

Comparison of adenoma detection and miss rates between a novel balloon colonoscope and standard colonoscopy: a randomized tandem study

BACKGROUND AND STUDY AIMSnAlthough colonoscopy is the gold standard for colorectal cancer screening, a significant number of adenomas are still missed during standard colonoscopy, often because they are hidden behind colonic folds and flexures. The aim of this study was to assess the ability of a novel balloon colonoscope (G-EYE endoscope; Smart Medical Systems, Raanana, Israel) to increase adenoma detection and reduce the miss rate compared with standard colonoscopy.nnnPATIENTS AND METHODSnThis was a multicenter, randomized, prospective, controlled study in patients (ageu200a≥u200a40 years) undergoing colonoscopy for screening or diagnostic work-up (including surveillance). Patients underwent same-day, back-to-back tandem colonoscopy. Patients in Group A underwent standard colonoscopy followed by balloon colonoscopy, and patients in Group B underwent balloon colonoscopy followed by the standard technique. The adenoma detection and miss rates were compared between the two colonoscopy procedures.nnnRESULTSnA total of 126 patients were enrolled and randomized into Group A (nu200a=u200a60) or Group B (nu200a=u200a66). The adenoma miss rate of balloon colonoscopy was significantly lower than that of standard colonoscopy (7.5u200a% vs. 44.7u200a%; Pu200a=u200a0.0002). The detection of additional adenomas by balloon colonoscopy was significant (81.0u200a%; Pu200a=u200a0.0002), in particular, the relative amount of adenomas detected in the ascending colon by balloon colonoscopy was 41u200a% versus 14u200a% for standard colonoscopy.nnnCONCLUSIONSnA novel balloon colonoscopy technique detected significantly more adenomas than standard colonoscopy, and missed fewer adenomas. Balloon colonoscopy has the potential to increase the effectiveness of colorectal cancer screening and surveillance colonoscopy.

Deep enteroscopy with a conventional colonoscope: initial multicenter study by using a through-the-scope balloon catheter system

BACKGROUND AND AIMSnThe advent of capsule endoscopy has revolutionized evaluation of the small bowel. Capsule endoscopy has become the criterion standard as the initial examination to diagnose small-bowel abnormalities, but does not allow for tissue sampling or therapeutic intervention. Deep enteroscopy can be performed by using a balloon-assisted device or a spiral overtube for both diagnostic and therapeutic interventions of the small bowel. Deep enteroscopy is time-consuming and requires special endoscopes and accessories to perform the examination. We studied a novel through-the-scope balloon catheter system used for deep enteroscopy that uses a conventional colonoscope and standard accessories.nnnMETHODSnWe performed a 9-center, retrospective study using a novel TTS balloon system for small-bowel evaluation. The new through-the-scope device is an on-demand balloon catheter that is inserted through the instrument channel of a standard colonoscope and enables deep advancement into the small bowel in either the anterograde or retrograde approach. It consists of a balloon inflation/deflation system and a single-use balloon catheter designed for anchoring in the small bowel. The balloon is inflated to an anchoring pressure in the small intestine, and a repetitive push-pull technique is performed, with the endoscope sliding over the guiding catheter to the inflated balloon. The catheter may be removed and reinserted to allow for therapeutic intervention while maintaining the endoscope position.nnnRESULTSnA total of 98 patients were included; 52% were male, and the mean age was 55 years old (range 15-94 years). Indications included abdominal pain, iron-deficiency anemia, occult GI bleeding, diarrhea, abnormal capsule endoscopy, weight loss, protein losing enteropathy, retained foreign body, altered anatomy ERCP, and small-bowel strictures. Anterograde enteroscopy was performed in 65 patients. The average depth of insertion was 158 cm (range 50-350 cm) from the pylorus. Retrograde enteroscopy was performed in 33 cases. The average depth of insertion was 89 cm (range 20-150 cm) beyond the ileocecal valve. Overall, diagnostic yield was 44%. Thexa0average advancement time for the anterograde and retrograde enteroscopy cases was 15.5 minutes. Therexa0were no procedural adverse outcomes reported in the 98 cases.nnnCONCLUSIONSnThe TTS advancing balloon is a safe and effective way to perform deep enteroscopy by using axa0conventional colonoscope without the need for an overtube. Procedure time is shorter than that of other formsxa0of deep enteroscopy. Diagnostic yield and depth of insertion are on par with other forms of deep enteroscopy. This is the largest reported study using this novel technology to diagnose and treat small-bowel disease.

Characteristics of gastrointestinal bleeding after placement of continuous-flow left ventricular assist device: a case series.

AbstractBackgroundnMedical management of patients with continuous-flow left ventricular assist devices (LVADs) remains challenging for the gastroenterologist given their high risk of gastrointestinal bleeding (GIB) and need for continuous anticoagulation.AimsOur aim was to better characterize LVAD patients who presented with a GIB at our facility and delineate the prevalence, presentation, time to diagnosis, management, and therapeutic endoscopic interventions, includingxa0small bowel tools that may offer additional benefit.MethodsWe retrospectively reviewed adult patients (>18xa0years) who underwent LVAD implantation at our tertiary care facility between October 2011 and October 2013. Electronic medical records were reviewed for presenting symptoms, average days to initial and repeat GIB, hospital course, and techniques that led to diagnosis and hemostasis.ResultsEighteen patients underwent LVAD implantation, of which 61xa0% presented with a GIB for a total of 20 presentations (1.8 per patient). Mean time to initial GIB was 154xa0days. Patients required an average of 1.8 endoscopic procedures per admission. Esophagogastroduodenoscopy (EGD) and push enteroscopy (PE) were more likely to lead to a diagnosis, and EGD was the most commonly used diagnostic tool at initial presentation. Sixty percent of patients who initially received EGD presented with a recurrent GIB and required PE, which was diagnostic and therapeutic for small bowel angiodysplasias in 80xa0% of cases.ConclusionWe found a higher GIB rate compared with prior studies. Bleeding events were associated with multiple procedures and interventions. We recommend an algorithmic approach to LVAD patients who bleed. Our experience suggests that PE is warranted at initial presentationxa0in order to achieve hemostasis, prevent recurrent GIB, and decrease subsequent readmission rates.

A novel balloon colonoscope detects significantly more simulated polyps than a standard colonoscope in a colon model.

BACKGROUNDnAlthough standard colonoscopy is considered the optimal test to detect adenomas, it can have a significant adenoma miss rate. A major contributing factor to high miss rates is the inability to visualize adenomas behind haustral folds and at anatomic flexures.nnnOBJECTIVEnTo compare the diagnostic yield of balloon-assisted colonoscopy versus standard colonoscopy in the detection of simulated polyps in a colon model.nnnDESIGNnProspective, cohort study.nnnSETTINGnInternational gastroenterology meeting.nnnSUBJECTnA colon model composed of elastic material, which mimics the flexible structure of haustral folds, allowing for dynamic responses to balloon inflation, with embedded simulated colon polyps (n = 12 silicone polyps).nnnINTERVENTIONSnFifty gastroenterologists were recruited to identify simulated colon polyps in a colon model, first using standard colonoscopy immediately followed by balloon-assisted colonoscopy.nnnMAIN OUTCOME MEASUREMENTSnDetection of simulated polyps.nnnRESULTSnThe median polyp detection rate for all simulated polyps was significantly higher with balloon-assisted as compared with standard colonoscopy (91.7% vs 45.8%, respectively; P < .0001). The significantly higher simulated polyp detection rate with balloon-assisted versus standard colonoscopy was notable both for non-obscured polyps (100.0% vs 75.0%; P < .0001) and obscured polyps (88.0% vs 25.0%; P < .0001).nnnLIMITATIONSnNon-randomized design, use of a colon model, and simulated colon polyps.nnnCONCLUSIONnAs compared with standard colonoscopy, balloon-assisted colonoscopy detected significantly more obscured and non-obscured simulated polyps in a colon model. Clinical studies in human participants are being pursued to further evaluate this new colonoscopic technology.

Increased Post-procedural Non-gastrointestinal Adverse Events After Outpatient Colonoscopy in High-risk Patients

Background & Aims The incidence and predictors of non‐gastrointestinal (GI) adverse events (AEs) after colonoscopy are not well‐understood. We studied the effects of antithrombotic agents, cardiopulmonary comorbidities, and age on risk of non‐GI AEs after colonoscopy. Methods We performed a retrospective longitudinal analysis to assess the diagnosis, procedure, and prescription drug codes in a United States commercial claims database (March 2010–March 2012). Data from patients at increased risk (n = 82,025; defined as patients with pulmonary comorbidities or cardiovascular disease requiring antithrombotic medications) were compared with data from 398,663 average‐risk patients. In a 1:1 matched analysis, 51,932 patients at increased risk, examined by colonoscopy, were compared with 51,932 matched (on the basis of age, sex, and comorbidities) patients at increased risk who did not undergo colonoscopy. We tracked cardiac, pulmonary, and neurovascular events 1–30 days after colonoscopy. Results Thirty days after outpatient colonoscopy, non‐GI AEs were significantly higher in patients taking antithrombotic medications (7.3%; odds ratio [OR], 10.75; 95% confidence interval, 10.13–11.42) or those with pulmonary comorbidities (1.8%; OR, 2.44; 95% confidence interval, 2.27–2.62) vs average‐risk patients (0.7%) and in patients 60–69 years old (OR, 2.21; 95% confidence interval, 2.01–2.42) or 70 years or older (OR, 6.45; 95% confidence interval, 5.89–7.06), compared with patients younger than 50 years. The 30‐day incidence of non‐GI AEs in patients at increased risk who underwent colonoscopy was also significantly higher than in matched patients at increased risk who did not undergo colonoscopy in the anticoagulant group (OR, 2.31; 95% confidence interval, 2.01–2.65) and in the chronic obstructive pulmonary disease group (OR, 1.33; 95% confidence interval, 1.13–1.56). Conclusions Increased number of comorbidities and older age (older than 60 years) are associated with increased risk of non‐GI AEs after colonoscopy. These findings indicate the importance of determining comorbid risk and evaluating antithrombotic management before colonoscopy.

Making the Cut: An Isolated Filiform Polyp

75-year-old woman with a remote history of sigAmoidectomy for perforated diverticulitis, as well as benign colonic polyps found during colonoscopy 4 years prior, presented for surveillance colonoscopy. During colonoscopy, an isolated, 3 cm in length, pedunculated, worm-like polyp was discovered at 40 cm proximal to the anus (Figure A). Initial hot snare polypectomy, set at 25 W, cut through the outermost layer of stalk tissue but failed to cut through the central fibrous-appearing core. Of note, the stalk of the polyp was noted to contract with application of current. By using the autocut function set at 180 W, the central core was successfully cut (Figure B). The polyp was retrieved, and hemostatic clips were placed to prevent post-polypectomy bleeding. Pathologic examination revealed a finger-like polyp lined by benign reactive colonic epithelium and containing a central fibrovascular core, which was negative for dysplasia (Figure C). There were no post-procedural adverse events. Filiform polyps are most commonly associated with inflammatory bowel disease but may also be seen with diverticulitis and malignancy. Differing from this case, filiform polyps more commonly are found as a group of polyps or even as mass-like agglomerations. Histologic examination of filiform polyps reveals nonspecific inflammation of colonic mucosa with a core that is often fibrovascular but can also contain disordered smooth muscle fascicles and nerves. These muscle fascicles are believed to be the cause of polyp contraction with application of current during this case. Filiform polyps generally are not thought to have malignant potential. However, endoscopists should consider polypectomy or biopsy if the polyp is of uncertain histology. This was an atypical, isolated filiform polyp found during colonoscopy, and thus the endoscopists chose to proceed with polypectomy. A previous report suggested a snare and cautery technique for removal of suspected filiform polyps. However, because of the fibrovascular and muscular core of these polyps, autocut may be more successful for polypectomy of a suspected filiform polyp.

Gastric variceal bleeding due to pancreatitis-induced splenic vein thrombosis.

Obscure gastrointestinal bleeding is a common clinical scenario. In the upper gastrointestinal tract, gastric varices can be frequently overlooked on endoscopy, particularly if not suspected or volume depleted. We report a case of suspected gastrointestinal bleeding in a patient with a childhood history of pancreatitis, who also experienced severe epigastric pain while in hospital. After transfer to an academic medical centre, the presence of gastric varices was identified and presumed to be due to splenic vein thrombosis. Pancreatitis is the most common cause of splenic vein thrombosis and accords with the patients history, even though it occurred many years previously. This case highlights the importance of recognising pancreatitis-induced splenic vein thrombosis as a possible aetiology for upper gastrointestinal bleeding.

Quality commitment: the newly established American College of Gastroenterology Quality Council to meet the needs of clinical gastroenterology.

Quality Commitment: The Newly Established American College of Gastroenterology Quality Council to Meet the Needs of Clinical Gastroenterology