Miguel Muñoz-Navas

Capsule endoscopy versus colonoscopy for the detection of polyps and cancer.

BACKGROUND An ingestible capsule consisting of an endoscope equipped with a video camera at both ends was designed to explore the colon. This study compared capsule endoscopy with optical colonoscopy for the detection of colorectal polyps and cancer. METHODS We performed a prospective, multicenter study comparing capsule endoscopy with optical colonoscopy (the standard for comparison) in a cohort of patients with known or suspected colonic disease for the detection of colorectal polyps or cancer. Patients underwent an adapted colon preparation, and colon cleanliness was graded from poor to excellent. We computed the sensitivity and specificity of capsule endoscopy for polyps, advanced adenoma, and cancer. RESULTS A total of 328 patients (mean age, 58.6 years) were included in the study. The capsule was excreted within 10 hours after ingestion and before the end of the lifetime of the battery in 92.8% of the patients. The sensitivity and specificity of capsule endoscopy for detecting polyps that were 6 mm in size or bigger were 64% (95% confidence interval [CI], 59 to 72) and 84% (95% CI, 81 to 87), respectively, and for detecting advanced adenoma, the sensitivity and specificity were 73% (95% CI, 61 to 83) and 79% (95% CI, 77 to 81), respectively. Of 19 cancers detected by colonoscopy, 14 were detected by capsule endoscopy (sensitivity, 74%; 95% CI, 52 to 88). For all lesions, the sensitivity of capsule endoscopy was higher in patients with good or excellent colon cleanliness than in those with fair or poor colon cleanliness. Mild-to-moderate adverse events were reported in 26 patients (7.9%) and were mostly related to the colon preparation. CONCLUSIONS The use of capsule endoscopy of the colon allows visualization of the colonic mucosa in most patients, but its sensitivity for detecting colonic lesions is low as compared with the use of optical colonoscopy. (ClinicalTrials.gov number, NCT00604162.)

Second-generation colon capsule endoscopy compared with colonoscopy

BACKGROUND Colon capsule endoscopy (CCE) represents a noninvasive technology that allows visualization of the colon without requiring sedation and air insufflation. A second-generation colon capsule endoscopy system (PillCam Colon 2) (CCE-2) was developed to increase sensitivity for colorectal polyp detection compared with the first-generation system. OBJECTIVE To assess the feasibility, accuracy, and safety of CCE-2 in a head-to-head comparison with colonoscopy. DESIGN AND SETTING Prospective, multicenter trial including 8 European sites. PATIENTS This study involved 117 patients (mean age 60 years). Data from 109 patients were analyzed. INTERVENTION CCE-2 was prospectively compared with conventional colonoscopy as the criterion standard for the detection of colorectal polyps that are ≥6 mm or masses in a cohort of patients at average or increased risk of colorectal neoplasia. Colonoscopy was independently performed within 10 hours after capsule ingestion or on the next day. MAIN OUTCOME MEASUREMENTS CCE-2 sensitivity and specificity for detecting patients with polyps ≥6 mm and ≥10 mm were assessed. Capsule-positive but colonoscopy-negative cases were counted as false positive. Capsule excretion rate, level of bowel preparation, and rate of adverse events also were assessed. RESULTS Per-patient CCE-2 sensitivity for polyps ≥6 mm and ≥10 mm was 84% and 88%, with specificities of 64% and 95%, respectively. All 3 invasive carcinomas were detected by CCE-2. The capsule excretion rate was 88% within 10 hours. Overall colon cleanliness for CCE-2 was adequate in 81% of patients. LIMITATIONS Not unblinding the CCE-2 results at colonoscopy; heterogenous patient population; nonconsecutive patients. CONCLUSION In this European, multicenter study, CCE-2 appeared to have a high sensitivity for the detection of clinically relevant polypoid lesions, and it might be considered an adequate tool for colorectal imaging.

Use of colonoscopy as a primary screening test for colorectal cancer in average risk people

OBJECTIVE:The use of colonoscopy as a primary screening test for colorectal cancer (CRC) in average risk adults is a subject of controversy. Our primary objective was to build a predictive model based on a few simple variables that could be used as a guide for identifying average risk adults more suitable for examination with colonoscopy as a primary screening test.METHODS:The prevalence of advanced adenomas was assessed by primary screening colonoscopy in 2210 consecutive adults at least 40 yr old, without known risk factors for CRC. Age, gender, and clinical and biochemical data were compared among people without adenomas, those with nonadvanced adenomas, and those with any advanced neoplasm. A combined score to assess the risk of advanced adenomas was built with the variables selected by multiple logistic regression analysis.RESULTS:Neoplastic lesions were found in 617 subjects (27.9%), including 259 with at least one neoplasm that was 10 mm or larger, villous, or with moderate-to-severe dysplasia, and 11 with invasive cancers. Advanced lesions were more frequent among men, older people, and those with a higher body mass index (BMI). These three variables were independent predictors of advanced adenomas in multivariate analysis. A score combining age, sex, and BMI was developed as a guide for identifying individuals more suitable for screening colonoscopy.CONCLUSIONS:Age, gender, and BMI can be used to build a simple score to select those average risk adults who might be candidates for primary screening colonoscopy.

Colon capsule endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

PillCam colon capsule endoscopy (CCE) is an innovative noninvasive, and painless ingestible capsule technique that allows exploration of the colon without the need for sedation and gas insufflation. Although it is already available in European and other countries, the clinical indications for CCE as well as the reporting and work-up of detected findings have not yet been standardized. The aim of this evidence-based and consensus-based guideline, commissioned by the European Society of Gastrointestinal Endoscopy (ESGE) is to furnish healthcare providers with a comprehensive framework for potential implementation of this technique in a clinical setting.

Gastroduodenal Injury After Radioembolization of Hepatic Tumors

BACKGROUND:Radioembolization is a new tool for the treatment of hepatic tumors that consists in the injection of biocompatible microspheres carrying radioisotopes into the hepatic artery or its branches.METHODS:We have performed radioembolization in 78 patients with hepatic tumors using resin-based microspheres loaded with yttrium-90. All patients were previously evaluated to minimize the risk of hazardous irradiation to nontarget organs and to obtain the data needed for dose calculation.RESULTS:We report a complication found in three cases (3.8%) that consists of abdominal pain resulting from gastroduodenal lesions and that had a chronic, insidious course. Microscopically, microspheres were detected in the specimens obtained from all affected gastric areas. Since these gastroduodenal lesions do not appear when nonradiating microspheres are injected in animals, lesions are likely to be due to radiation and not to an ischemic effect of vascular occlusion by spheres.CONCLUSIONS:We believe that a pretreatment evaluation that includes a more thorough scrutiny of the hepatic vascularization in search of small collaterals connecting to the gastroduodenal tract can help prevent this awkward complication.

EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: a multicenter study (with videos)

BACKGROUND Therapy of gastric varices (GV) is still challenging. Cyanoacrylate (CYA) injection is the recommended treatment for bleeding GV, but has a known adverse event rate, which could be reduced if EUS is used for guidance. Otherwise, EUS-guided coil application (ECA) may be an alternative. OBJECTIVES To compare CYA and ECA embolization of feeding GV for feasibility, safety, and applicability. DESIGN Retrospective analysis of a prospectively maintained database. SETTING Multicenter study, tertiary referral centers. PATIENTS AND INTERVENTIONS Thirty consecutive patients with localized GV who received either CYA injection or ECA were included with follow-up for 6 months after treatment. RESULTS There were 11 patients in the coil group and 19 patients in the CYA group. The GV obliteration rate was 94.7% CYA versus 90.9% ECA; mean number of endoscopy sessions was 1.4 ± 0.1 (range 1-3). Adverse events occurred in 12 of 30 patients (40%) (CYA, 11/19 [57.9%]; ECA, 1/11 [9.1%]; P < .01); only 3 were symptomatic, and an additional 9 (CYA group) had glue embolism on a CT scan but was asymptomatic. No further adverse events occurred during follow-up. Six patients (20%) died unrelated to the procedures or bleeding. LIMITATIONS Nonrandomized; EUS expertise necessary. CONCLUSIONS EUS-guided therapy for GV by using CYA or ECA is effective in localized GV. ECA required fewer endoscopies and tended to have fewer adverse events compared with CYA injection. Larger comparative studies are needed to prove these data.

Current endoscopic techniques in the treatment of obesity

BACKGROUND in recent years new endoscopic strategies and techniques for the treatment of obesity have emerged and developed. AIM OF THE STUDY in this article we will review and analyze the current state of the following techniques and the basic differential characteristics between each of them: balloons and prosthesis, injection of substances, systems of sutures, malabsorptives techniques and others currently in research. METHODS we will evaluate the endoscopic technique and their main indications, results, tolerances, complications and adverse effects observed, reporting our personal experience and in relation with an extensive literature review. RESULTS comparatively with the most widespread technique of the Bioenterics balloon, the Spatz balloon can provide greater weight loss but with worse tolerance and more complications and the Heliosphere Bag gets a similar weight loss but with greater technical difficulty. Other balloons and prosthesis (Ullorex, Semistationary, Silimed, Endogast) still require technical improvements and higher studies. The injection of botulinum toxin, although secure, seems to offer a smaller and more transient efficacy. Suture systems (TOGa, endoluminal vertical gastroplasty and POSE) appear to be effective but are technically more laborious. Malabsorptives procedures (Endobarrier, ValenTX) are somewhat laborious but effective, particularly indicated in obese patients with type 2 diabetes mellitus. CONCLUSIONS the development of new endoscopic techniques and improvement in existing designs, suggest an increasingly important role of the endoscopist in the treatment of obesity. We consider it important to individually select and use the endoscopic technique, depending on the desirable outcomes (efficacy, tolerance, safety, adverse effects and risks) and the experience of each hospital. We believe that these techniques should be applied by specifically trained endoscopists in specialized hospitals.

Diagnostic value of distal colonic polyps for prediction of advanced proximal neoplasia in an average-risk population undergoing screening colonoscopy

BACKGROUND For colorectal cancer screening, the predictive value of distal findings in the ascertainment of proximal lesions is not fully established. The aims of this study were to assess distal findings as predictors of advanced proximal neoplasia and to compare the predictive value of endoscopy alone vs. combined endoscopic and histopathologic data. METHODS Primary colonoscopy screening was performed in 2210 consecutive, average-risk adults. Age, gender, endoscopic (size, number of polyps), and histopathologic distal findings were used as potential predictors of advanced proximal neoplasms (i.e., any adenoma > or =1 cm in size, and/or with villous histology, and/or with severe dysplasia or invasive cancer). Polyps were defined as distal if located in the descending colon, the sigmoid colon, or the rectum. Those in other locations were designated proximal. RESULTS Neoplastic lesions, including 11 invasive cancers, were found in 617 (27.9%) patients. Advanced proximal neoplasms without any distal adenoma were present in 1.3% of patients. Of the advanced proximal lesions, 39% were not associated with any distal polyp. Older age, male gender, and distal adenoma were independent predictors of advanced proximal neoplasms. The predictive ability of a model with endoscopic data alone did not improve after inclusion of histopathologic data. In multivariate logistic regression analysis, the predictive ability of models that use age, gender, and any combination of distal findings was relatively low. The proportion of advanced proximal neoplasms identified if any distal polyp was an indication for colonoscopy was only 62%. CONCLUSIONS A strategy in which colonoscopy is performed solely in patients with distal colonic findings is not effective screening for the detection of advanced proximal neoplasms in an average-risk population.

Gallbladder drainage guided by endoscopic ultrasound

The gold-standard management of acute cholecystitis is cholecystectomy. Surgical intervention may be contraindicated due to permanent causes. To date, the classical approach is percutaneous cholecystostomy in patients unresponsive to medical therapy. However, with this treatment some patients may experience discomfort, complications and a decrease in their quality of life. In these cases, endoscopic ultrasound (EUS)-guided gallbladder drainage may represent an effective minimally invasive alternative. Our objective is to describe in detail this new and not well-known technique: EUS-guided cholecystenterostomy. We will describe how the patient should be prepared, what accessories are needed and how the technique is performed. We will also discuss the possible indications for this technique and will provide a brief review based on published reports and our own experience.

Caustic colitis due to formalin enema

Colitis has been reported by rectal instillation of a variety of agents: soap enemas, water-soluble contrast media, hydrogen peroxide, vinegar, potassium dichromate, potassium permanganate, copper sulfate, brown sugar, glutaraldehyde, non-steroidal anti-inflammatory agents, and ethyl alcohol. We report a 54-year-old man, who accidentally received a 100-ml enema of 10% formalin. Within minutes the patient experienced severe sharp pain located in the left lower abdomen followed by rectal bleeding. Five days later, colonoscopic examination revealed an edematous and erythematous mucosa with multiple petechiae and superficial erosions in the rectum and sigmoid up to 25 cm from the anal verge. Histology showed a nonspecific chronic colitis, superficial erosions, lymphocytes and plasma cells infiltrate, and erythrocyte extravasation. Following treatment with corticosteroid enemas rapid improvement was achieved. Two months later he was asymptomatic and endoscopy showed a distensible rectum with almost complete resolution of colitis. Biopsies revealed a very mild non-specific colitis in a regenerative phase. Currently, 2 years later, the patient is asymptomatic. The severity of the acute colonic damage after caustic enema depends on the chemical constituent, the concentration of the solution as well as the duration of mucosal contact. Between the third and fifth week, a cicatrization phase begins; afterward the lesion may progress to stricture formation, a complication that did not occur in our patient. Corticosteroids or ACTH have been employed, but we have not found other cases managed with corticosteroid enemas. To our knowledge, this is the first reported case of acute colitis due to rectal administration of formalin.