Martin Kliment

Combination of water immersion and carbon dioxide insufflation for minimal sedation colonoscopy: a prospective, randomized, single-center trial.

Objective Water immersion insertion and carbon dioxide (CO2) insufflation, as alternative colonoscopic techniques, are able to reduce patient discomfort during and after the procedure. We assessed whether the combination of water immersion and CO2 insufflation is superior in efficacy and patient comfort to other colonoscopic techniques. Methods In a prospective, randomized study, a total of 420 patients were randomized to either water immersion insertion and CO2 insufflation during withdrawal (water/CO2), water insertion and air insufflation during withdrawal (water/air), CO2 insufflation during both insertion and withdrawal (CO2/CO2), or air insufflation during both insertion and withdrawal (air/air). The main outcome was the success of minimal sedation colonoscopy, which was defined as reaching the cecum without switching to another insertion method and without additional sedation beyond the initial 2 mg of midazolam. Patient comfort during and after the procedure was assessed. Results A total of 404 patients were analyzed. The success rate of minimal sedation colonoscopy in the water insertion arm (water/CO2 and water/air) was 97% compared with 83.3% in the gas insertion arm (CO2/CO2 and air/air; P<0.0001). Intraprocedural pain and bloating were significantly lower in the water/CO2 group than in all other groups. Patient discomfort in the water/CO2 group during 24 h after the procedure was comparable with that in the CO2/CO2 group and significantly lower than that in the air groups (water/air and air/air). No complications were recorded during the study. Conclusion The combination of water immersion and CO2 insufflation appears to be an effective and safe method for minimal sedation colonoscopy. Overall patient discomfort was significantly reduced compared with that in other techniques.

Endoscopic ultrasound-guided fine needle aspiration of pancreatic masses: The utility and impact on management of patients

Abstract Objective. It is controversial whether endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is beneficial in all patients with suspected pancreatic cancer. The aim of this study was to assess diagnostic yield, safety and impact of EUS-FNA on management of patients with solid pancreatic mass. Material and methods. Consecutive patients undergoing EUS-FNA of solid pancreatic mass were enrolled. Gold standard for final diagnosis included histology from surgical resection. In patients without surgery, clinical evaluation methods and repeated imaging studies were used for the comparison of initial cytology and final diagnosis. Patients were followed-up prospectively focusing on subsequent treatment. Results. Among 207 enrolled patients, final diagnosis was malignant in 163 (78.6%) and benign in 44 (21.4%). The sensitivity, specificity and accuracy of EUS-FNA in diagnosing pancreatic cancer were 92.6% (95% CI: 87.20–95.96), 88.6% (95% CI: 74.64–95.64) and 91.8% (95% CI: 87.24–94.81), respectively. No major and five (2.4%) minor complications occurred. Of 151 true-positive patients by EUS-FNA, 57 (37.7%) were surgically explored, of whom 28 (49.1%) underwent resection. Ten of 12 patients with false-negative cytology were explored based on detection of mass on EUS, of whom two had a delay due to false-negative cytology without curative treatment. From the whole study cohort, EUS-FNA had positive and negative impacts on subsequent management in 136 (65.7%) and 2 (0.9%) patients, respectively. Conclusions. EUS-FNA provides accurate diagnosis in 92% and has positive therapeutic impact in two-thirds of patients with solid pancreatic mass. Despite negative cytology, surgical exploration is recommended in clinical suspicion for pancreatic cancer and solid mass on EUS.

Cap-assisted water immersion for minimal sedation colonoscopy: Prospective, randomized, single-center trial

Water immersion insertion is able to reduce discomfort and need for sedation during colonoscopy. A cap attached to the colonoscope tip may improve insertion during air insufflation colonoscopy. According to several reports, both techniques alone may result in higher detection of neoplastic lesions. Our study was designed to evaluate the efficacy of cap‐assisted water immersion compared to water immersion colonoscopy in minimally sedated patients.

High-frequency ultrasound probe sonography staging for colorectal neoplasia with superficial morphology: its utility and impact on patient management

BackgroundThis prospective study aimed to evaluate the impact of high-frequency ultrasound probe sonography (HFUPS) staging on the management of patients with superficial colorectal neoplasia (SCN) as determined by the endoscopic characteristics of lesions.MethodsConsecutive patients referred for endoscopic treatment of nonpedunculated SCN were enrolled in this study. A lesion was considered high risk if a depressed area or invasive pit pattern was present. The gold standard for final staging included histology from endoscopic or surgical resection. The impact on treatment was defined as any modification of the therapeutic algorithm based on the result of the HFUPS examination compared with that based on endoscopy alone.ResultsIn this study, 48 lesions in 48 patients were evaluated. Of these, 28 (58%) were considered high risk, and the remaining 20 (42%) were regarded as low risk. A total of seven lesions (15%) that could not be examined with HFUPS and another non-neoplastic lesion were excluded from final analysis. For the remaining 40 lesions, the overall accuracy of the HFUPS examination to predict the correct T-stage was 90% (95% confidence interval [CI], 77–96%). The HFUPS examination had a positive impact on the treatment of 0 low-risk and 11 high-risk (42%) lesions.ConclusionThe impact of HFUPS on the treatment of SCN depends on their endoscopic characteristics. It is negligible for low-risk SCNs, and these lesions can be treated on the basis of their endoscopic appearance alone. Nevertheless, compared with endoscopy alone, HFUPS changed the subsequent therapeutic approach in a positive way for up to 42% of high-risk lesions, including those with a depressed component and an invasive pit pattern. These endoscopic features can therefore be recommended as the entry criteria for an HFUPS examination.

Local residual neoplasia after endoscopic treatment of laterally spreading tumors during 15 months of follow-up.

Background Among superficial neoplastic lesions of the colon and rectum, a laterally spreading tumor (LST) is a flat elevated type at least 10 mm in size. It can be treated by conventional endoscopic resection (CER). Nevertheless, local residual neoplasia (LRN) may occur during follow-up. The aim of this prospective study was to evaluate the occurrence of LRN and the risk factors for its presence. Methods Consecutive patients referred for CER of an LST were included. Follow-up colonoscopies were performed after 3 and 15 months. LRN was defined histologically as the presence of neoplastic tissue in the post-CER site. Results Of a total of 127 patients with 127 lesions, follow-up could not be completed in 48 (37.8%). Of the remaining 79 (62.2%) patients (64.6% men, mean age 66.1±9.7 years), 63 (79.7%) were negative and 16 (20.3%) were positive for the presence of LRN after 15 months. Of 62 (78.5%) patients without LRN after 3 months, 55 (88.7%) remained negative after 15 months. Of 17 (21.5%) patients with LRN after 3 months, eight (47.1%) were negative after 15 months. In a multivariate analysis, LST size of at least 20 mm was found to be a significant risk factor after 3 months (odds ratio, 5.837; 95% confidence interval 1.199–28.425; P=0.029). After 15 months, the only significant risk factor was the presence of LRN observed after 3 months (odds ratio, 6.0; 95% confidence interval, 1.793–20.073; P=0.004). Conclusion This prospective study shows that the occurrence of LRN is frequent and its treatment is less effective than reported previously. These are important limitations of CER and should be taken into consideration for the management of patients with LSTs.

Digital cholangioscopy: the diagnostic yield and impact on management of patients with biliary stricture

Abstract: Objectives: Biliary strictures frequently present a diagnostic challenge. The aim of this study was to evaluate the impact of digital single-operator cholangioscopy (DSOC) on subsequent treatment of patients with biliary stricture. Methods: Consecutive patients undergoing DSOC for biliary stricture were enrolled. Gold standard for final diagnosis included histology from surgical resection. In patients without surgery, clinical evaluation methods and repeated imaging studies were used for comparison of DSOC findings and final diagnosis. Patients were followed-up prospectively focusing on subsequent treatment. Results: Among 30 enrolled patients, final diagnosis was malignant in 13 (43%) and benign in 17 (57%). The sensitivity and specificity of visual impression in diagnosing malignant stricture were 100% (95% CI: 75 − 100) and 76% (95% CI: 50 − 93), respectively. The sensitivity and specificity for biopsy were 92% (95% CI: 62 − 100) and 100% (95% CI: 78 − 100), respectively. One (3%) case of complicating cholangitis with fatal outcome occurred. Final treatment included surgery in 7 (23%), endoscopy in 18 (60%) and chemotherapy in 3 (10%) of patients. Conclusions: In this study, favorable operating characteristics of DSOC were confirmed. Absolute negative predictive value of visual impression provided reassurance to patients with benign strictures who avoided unnecessary surgery in 53%. One (3%) case of cholangitis with fatal outcome occurred.

Nutrition and Osteoporosis

Nutrition in treatment of osteoporosis is currently in the centre of attention of research activities as it contributes to bone quality throughout the whole life, during bone maturation as well as in adulthood. In addition to common therapeutic procedures consisting in pharmacological interventions, nutrition plays one of the key roles in treatment of advanced osteoporosis.

Coeliac Disease in Elderly Patients

Coeliac sprue is traditionally perceived as a disease related to early age, although young individuals may also suffer from typical bowel symptoms, which belong to the group of active coeliac syndromes. This opinion has been so far generally accepted by the medical public. Full-scale screening performed in the European countries and in the USA, however, has shown that the prevalence of this condition is about 1:100. It means that there are about 40,000–50,000 people affected by coeliac sprue in the Czech Republic, although currently the diagnosis has been established only in 15–20 % of the patients and the greater part of them remains undiagnosed. Thus, a majority of patients affected by coeliac disease are asymptomatic, oligosymptomatic, i.e. without typical intestinal symptoms of coeliac disease, and are therefore included in the category of atypical and silent coeliac disease (Table 21.1). This group comprises most adults without diagnosed coeliac disease. The most frequent atypical manifestation of the disease in adults and in the elderly is osteoporosis which, when combined in women with postmenopausal osteoporosis, may be difficult to treat. Therefore, attention should be paid to elderly patients with osteoporosis, where the incidence of coeliac disease may be expected in at least 3–6 % of patients.

Endoscopic drainage of pancreatic fluid collections – 6 years’ experience at a tertiary referral gastroenterological center in a period 2006–2012

M. Kliment1,2, O. Urban2,3, P. Fojtik2, M. Straka4, M. Lovecek5, J. Kratky6, P. Holeczy7 1 Gastroenterologie und Hepatologie, Klinik für Innere Medizin, Vivantes Klinikum Spandau, Berlin, Germany 2 Research Institute AGEL, Digestive Disease Center, Vitkovice Hospital, Ostrava, Czech Republic 3 Faculty of Medicine, University of Ostrava, Czech Republic 4 Department of Surgery, J. G. Mendel Oncological Center, Novy Jicin Hospital, Czech Republic 5 1st Department of Surgery, Faculty of Medicine, Palacky University, University Hospital Olomouc, Czech Republic 6 Department of Radiology, Vitkovice Hospital, Ostrava, Czech Republic 7 Department of Surgery, Vitkovice Hospital, Ostrava, Czech Republic