Ondřej Urban

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.

Water exchange for screening colonoscopy increases adenoma detection rate: a multicenter, double-blinded, randomized controlled trial

Background and study aims Single-center studies, which were retrospective and/or involved unblinded colonoscopists, have suggested that water exchange, but not water immersion, compared with air insufflation significantly increases the adenoma detection rate (ADR), particularly in the proximal and right colon. Head-to-head comparison of the three techniques with ADR as primary outcome and blinded colonoscopists has not been reported to date. In a randomized controlled trial with blinded colonoscopists, we aimed to evaluate the impact of the three insertion techniques on ADR. Patients and methods A total of 1224 patients aged 50 - 70 years (672 males) and undergoing screening colonoscopy were randomized 1:1:1 to water exchange, water immersion, or air insufflation. Split-dose bowel preparation was adopted to optimize colon cleansing. After the cecum had been reached, a second colonoscopist who was blinded to the insertion technique performed the withdrawal. The primary outcome was overall ADR according to the three insertion techniques (water exchange, water immersion, and air insufflation). Secondary outcomes were other pertinent overall and right colon procedure-related measures. Results Baseline characteristics of the three groups were comparable. Compared with air insufflation, water exchange achieved a significantly higher overall ADR (49.3 %, 95 % confidence interval [CI] 44.3 % - 54.2 % vs. 40.4 % 95 %CI 35.6 % - 45.3 %; P  = 0.03); water exchange showed comparable overall ADR vs. water immersion (43.4 %, 95 %CI 38.5 % - 48.3 %; P  = 0.28). In the right colon, water exchange achieved a higher ADR than air insufflation (24.0 %, 95 %CI 20.0 % - 28.5 % vs. 16.9 %, 95 %CI 13.4 % - 20.9 %; P  = 0.04) and a higher advanced ADR (6.1 %, 95 %CI 4.0 % - 9.0 % vs. 2.5 %, 95 %CI 1.2 % - 4.6 %; P = 0.03). Compared with air insufflation, the mean number of adenomas per procedure was significantly higher with water exchange (P = 0.04). Water exchange achieved the highest cleanliness scores (overall and in the right colon). These variables were comparable between water immersion and air insufflation. Conclusions The design with blinded observers strengthens the validity of the observation that water exchange, but not water immersion, can achieve significantly higher adenoma detection than air insufflation. Based on this evidence, the use of water exchange should be encouraged.Trial registered at ClinicalTrials.gov (NCT02041507).

Globus Pharyngeus and Extraesophageal Reflux: Simultaneous pH <4.0 and pH < 5. 0 Analysis

Weakly acid refluxes seem to play an important role in the pathogenesis of extraesophageal reflux. The aim of this study was to evaluate how proportional representation of patients with extraesophageal reflux in a group of patients with globus pharyngeus changes when we use both pH <4.0 as well as pH <5.0 as a pathological threshold for an extraesophageal reflux episode.

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.

Cool water vs warm water immersion for minimal sedation colonoscopy: a double‐blind randomized trial

Water‐aided insertion as an alternative colonoscopy technique reduces patient discomfort. Warm water has been used in most published trials, but the use of cool water is easier and, if equally effective, could support the use of the water‐aided technique in routine practice.

Comparison of Three Methods Used in the Diagnosis of Extraesophageal Reflux in Children with Chronic Otitis Media with Effusion.

Objectives. Detection of extraesophageal reflux (EER) in children with chronic otitis media with effusion (OME) using three different diagnostic methods. Methods. Children between 1 and 7 years with OME who underwent adenoidectomy and myringotomy with insertion of a ventilation tube were included in this prospective study. EER was detected using three methods: oropharyngeal pH was monitored for 24 hours using the Restech system; detection of pepsin in middle ear fluid obtained during myringotomy was done using Peptest, and detection of pepsin in an adenoid specimen was done immunohistochemically. Results. Altogether 21 children were included in the study. Pathological oropharyngeal pH was confirmed in 13/21 (61.9%) children. Pepsin in the middle ear fluid was present in 5/21 (23.8%) children; these 5 patients were diagnosed with the most severe EER established through monitoring of oropharyngeal pH. No specimen of adenoids tested was positive for pepsin upon immunohistochemical examination. Conclusions. Diagnosis of EER in patients with OME using Restech is sensitive but less specific when compared to the detection of pepsin in middle ear fluid using Peptest. Pepsin in the middle ear was consistently present in patients with RYAN score above 200, and these patients in particular could potentially profit from antireflux therapy.

Carbon dioxide insufflation during colonoscopy in inflammatory bowel disease patients: a double-blind, randomized, single-center trial

Objective Bowel distension by insufflated air causes abdominal discomfort after colonoscopy. Carbon dioxide (CO2) instead of air insufflation during colonoscopy can reduce postprocedural discomfort in diagnostic and screening cases. Discomfort after colonoscopy and CO2 insufflation have never been studied in inflammatory bowel disease (IBD) patients, characterized by younger age, structural changes of the colon, and need for repeated and frequently uncomfortable colonoscopies. Our trial was designed to evaluate postprocedural discomfort associated with CO2 compared with air insufflation in unsedated or minimally sedated patients with known IBD. Methods In a double-blind, randomized, single-center study, 64 patients were randomized to either CO2 insufflation (CO2) or air insufflation colonoscopy (Air). Abdominal pain, bloating, and flatulence scores during 24 h after colonoscopy were recorded using a continuous scale of 0–10 (0=none, 10=maximum discomfort). The primary endpoint used for power calculation was bloating score at 1 h after colonoscopy. Results Pain, bloating, and flatulence scores at end, 1, and 3 h after colonoscopy were significantly lower in CO2 than in Air arm (P<0.001). Scores at 6, 12, and 24 h were comparable. Procedural parameters such as cecal and terminal ileum intubation rate, intubation and total time, pain during insertion, need for repositioning, and abdominal compression were not different between arms. No complications were recorded in the study. Conclusion Compared with air, CO2 insufflation significantly reduces abdominal pain, bloating, and flatulence scores during at least 3 h after colonoscopy in IBD patients, achieving comparable intraprocedural outcomes.

Chromoendoscopy to Detect Early Synchronous Second Primary Esophageal Carcinoma in Patients with Squamous Cell Carcinomas of the Head and Neck

Objective. To evaluate the use of flexible esophagoscopy and chromoendoscopy with Lugols solution in the detection of early esophageal carcinomas (second primary carcinomas) in patients with squamous cell carcinoma of the head and neck (HNSCC). Methods. All patients with newly diagnosed HNSCC underwent office-based Lugols chromoendoscopy. After flexible esophagoscopy with white light, 3.0% Lugols iodine solution was sprayed over the entire esophageal mucosa. Areas with less-intense staining (LVLs) were evaluated and biopsies taken. Results. 132 patients with HNSCC were enrolled in this study. The most frequent primary tumors were oropharyngeal (49/132), tumors of the oral cavity (36/132), and larynx (35/132). The majority of subjects (107/132 patients, 81.1%) had advanced HNSCC carcinomas (stages III and IV). Multiple LVLs were discovered in 24 subjects (18.2%) and no LVLs in 108 (81.8%) subjects. Fifty-five LVL biopsy specimens were obtained and assessed. Squamous cell carcinomas were detected in two patients, peptic esophagitis in 11 patients, gastric heterotopic mucosa in two patients, hyperplasia in two patients, and low- and high-grade dysplasia in three patients. Conclusion. Although only two patients with synchronous primary carcinomas were found among the patients, esophagoscopy should be recommended after detection of HNSCC to exclude secondary esophageal carcinoma or dysplasia.

Endoscopic full-thickness resection for the treatment of local residual neoplastia in the colon – an analysis of 19 cases

P. Falt1,2, T. Hucl3, P. Fojtík4, P. Drastich3, J. Martínek3, R. Andělová5, L. Voska6, J. Špičák3, O. Urban1,2 1 II. interní klinika – gastroenterologie a geriatrie LF UP a FN Olomouc 2 Katedra interních oborů, LF UK v Hradci Králové 3 Klinika hepatogastroenterologie, Transplantcentrum, IKEM, Praha 4 Centrum péče o zažívací trakt, Vítkovická nemocnice a. s., Ostrava 5 Oddělení patologie, Nemocnice Nový Jičín a.s. 6 Pracoviště klinické a transplantační patologie, Transplantcentrum, IKEM, Praha

Comparison of Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection in the Treatment of Flat Neoplastic Lesions in the Rectum

Endoscopic submucosal dissection (ESD) is a method used for en bloc removal of colorectal lesions > 20 mm. A comparison of ESD and endoscopic mucosal resection (EMR) in the treatment of rectal flat neoplastic lesions is reported. A total of 27 and 30 patients were included in ESD and EMR group, respectively. En bloc resection was achieved in 21(78 %) vs. 2(7 %), (p < 0,005) while perforation not requiring surgery occurred in 3(11 %) vs. 0 (p= 0,099) and local residual neoplasia in 2(9 %) vs. 9 (41 %) cases (p = 0,017). There was no procedure related letality in either group. ESD seems to be a promising method for the treatment of rectal neoplastic lesions.