S Kunsch

Higher Adenoma Detection Rates with Endocuff-Assisted Colonoscopy – A Randomized Controlled Multicenter Trial

Objectives The Endocuff is a device mounted on the tip of the colonoscope to help flatten the colonic folds during withdrawal. This study aimed to compare the adenoma detection rates between Endocuff-assisted (EC) colonoscopy and standard colonoscopy (SC). Methods This randomized prospective multicenter trial was conducted at four academic endoscopy units in Germany. Participants: 500 patients (235 males, median age 64[IQR 54–73]) for colon adenoma detection purposes were included in the study. All patients were either allocated to EC or SC. The primary outcome measure was the determination of the adenoma detection rates (ADR). Results The ADR significantly increased with the use of the Endocuff compared to standard colonoscopy (35.4%[95% confidence interval{CI} 29–41%] vs. 20.7%[95%CI 15–26%], p<0.0001). Significantly more sessile polyps were detected by EC. Overall procedure time and withdrawal time did not differ. Caecal and ileum intubation rates were similar. No major adverse events occurred in both groups. In multivariate analysis, age (odds ratio [OR] 1.03; 95%[CI] 1.01–1.05), male sex (OR 1.74; 95%CI 1.10–2.73), withdrawal time (OR 1.16; 95%CI 1.05–1.30), procedure time (OR 1.07; 95%CI 1.04–1.10), colon cleanliness (OR 0.60; 95%CI 0.39–0.94) and use of Endocuff (OR 2.09; 95%CI 1.34–3.27) were independent predictors of adenoma detection rates. Conclusions EC increases the adenoma detection rate by 14.7%(95%CI 6.9–22.5%). EC is safe, effective, easy to handle and might reduce colorectal interval carcinomas. Trial Registration ClinicalTrials.gov NCT02034929.

Novel score for prediction of malignant bile duct obstruction based on biochemical and clinical markers

Early differentiation of malignant from benign bile duct obstruction is of utmost importance.

Individual endoscopic management of anastomotic insufficiency after esophagectomy for esophageal squamous cell carcinoma and creation of a neostomach

A 57-year-old patient with a T3, cN0, G2, M0 esophageal squamous cell cancer received neoadjuvant radiochemotherapy according to the CROSS trial. After successful esophagectomy and consecutive gastroesophageal anastomosis, the patient recovered appropriately. Unfortunately, the patient developed circular anastomotic insufficiency with two cavities at Day 7 (▶Fig. 1). One of the cavities arose from the circular insufficiency (2×2 cm), and the other was formed by a stapler insufficiency of the stomach (3×2 cm). The final tumor stage was histologically proven to be ypT0, N0, cM0, L0, V0, R0. We started repetitive endoluminal vacuum therapy (Endo-Sponge; B. Braun, Melsungen, Germany) for a treatment period of 2 months (▶Video1). Owing to the remarkable dimension of the cavities, we decided initially to place two devices per insufficiency (▶Fig. 2), and in total, 11 device replacements were performed. After 2 weeks of treatment, the use of one Endo-Sponge appeared to be sufficient to cover all areas of insufficiency. A negative intracavital pressure was applied (15–20mmHg) in order to avoid the development of pulmonary fistula. Antibiotic and antifungal treatment was also administered during the first 2 weeks of the vacuum therapy. The patient received parenteral nutrition but was allowed to drink liquids during the treatment period (▶Fig. 3). Unfortunately, despite appropriate endoscopic procedures and frequent Endo-Sponge exchange, the insufficiencies failed to heal and the cavities persisted. Therefore, a more aggressive endoscopic therapeutic approach was initiated (▶Video1). We utilized cytological brushes and argon plasma coagulation at the edges of cavital insufficiencies in order to induce vascular spreading and wound granulation (▶Fig. 4). Fibrotic tissue and surgical staple sutures were endoscopically removed using cutting devices and graspers. Mucosal bridges were cut by needle-knife incision, leading to development of a neostomach and esophagogastric continuity. In addition, epithelial mucosa spreading occurred, evolving from the upper esophageal tissue. After 2 months of endoscopic treatment, neither fistula nor anastomotic insufficiencies were detectable. In addition, a neostomach had been created, consisting of mediastinal parietal pleura, the distal esophagus, and the remnant stomE-Videos

Gall bladder wall thickening as non-invasive screening parameter for esophageal varices – a comparative endoscopic – sonographic study

BackgroundThe mortality due to hemorrhage of esophageal varices (EV) is still high. The predominant cause for EV is liver cirrhosis, which has a high prevalence in Western Europe. Therefore, non-invasive screening markers for the presence of EV are of interest. Here, we aim to investigate whether non-inflammatory gall bladder wall thickening (GBWT) may serve as predictor for the presence of EV in comparison and combination with other non-invasive clinical and laboratory parameters.MethodsOne hundred ninety four patients were retrospectively enrolled in the study. Abdominal ultrasound, upper endoscopy and blood tests were evaluated. GBWT, spleen size and the presence of ascites were evaluated by ultrasound. Platelet count and Child-Pugh-score were also recorded. The study population was categorized in two groups: 122 patients without esophageal varices (non EV) compared to 72 patients with EV were analyzed by uni-and multivariate analysis.ResultsIn the EV group 46% showed a non-inflammatory GBWT of ≥4xa0mm, compared to 12% in the non-EV group (pu2009<u20090.01). GBWT was significantly higher in EV patients compared to the non-EV group (mean: 4.4xa0mm vs. 2.8xa0mm, pu2009<u20090.0001), and multivariate analysis confirmed GBWT as independent predictor for EV (pu2009<u20090.04). The platelets/GBWT ratio (cut-off >u200946.2) had a sensitivity and specificity of 78 and 86%, PPV 76% and NPV of 87%, and ROC analysis calculated the AUC of 0.864 (CI 0.809–0.919).ConclusionsGBWT occurs significantly more often in patients with EV. However, because of the low sensitivity, combination with other non-invasive parameters such as platelet count is recommended.

A case report of delayed intra-abdominal and intra-luminal haemorrhage after polypectomy

We report the case of a 70-year-old man who presented with hematochezia, anaemia, and severe abdominal pain 6 days after polypectomy. Contrast-enhanced ultrasound and computed tomography revealed no signs of free intra-abdominal air but showed intra-abdominal and intra-luminal bleeding. The patient was referred to colonoscopy in the operation room, which showed a coagula and venous bleeding at the polypectomy site. Emergency laparotomy was performed and revealed a large intra-abdominal mesocolic hematoma, which was surgically removed. The patients post-operative recovery was uneventful. While few reports of splenic vessel rupture after colonoscopy due to traction on the splenocolic ligament have been published, delayed mesocolic hematoma without evidence of organ damage has not been reported so far. Clinicians need to be aware of these rare but life-threatening complications following colonoscopy.