Underwater versus conventional EMR of large nonpedunculated colorectal lesions: a multicenter randomized controlled trial.

BACKGROUND AND AIMS: Underwater EMR (UEMR) is an alternative procedure to conventional EMR (CEMR) to treat large, nonpedunculated colorectal lesions (LNPCLs). In this multicenter, randomized controlled clinical trial, we aimed to compare the efficacy and safety of UEMR versus CEMR on LNPCLs. METHODS: We conducted a multicenter, randomized controlled clinical trial from February 2018 to February 2020 in 11 hospitals in Spain. A total of 298 patients (311 lesions) were randomized to the UEMR (n = 149) and CEMR (n = 162) groups. The main outcome was the lesion recurrence rate in at least 1 follow-up colonoscopy. Secondary outcomes included technical aspects, en bloc resection rate, R0 resection rates, and adverse events, among others. RESULTS: There were no differences in the overall recurrence rate (9.5% UEMR vs 11.7% CEMR; absolute risk difference, -2.2%; 95% CI, -9.4 to 4.9). However, considering polyp sizes between 20 and 30 mm, the recurrence rate was lower for UEMR (3.4% UEMR vs 13.1% CEMR; absolute risk difference, -9.7%; 95% CI, -19.4 to 0). The R0 resection showed the same tendency, with significant differences favoring UEMR only for polyps between 20 and 30 mm. Overall, UEMR was faster and easier to perform than CEMR. Importantly, the techniques were equally safe. CONCLUSIONS: UEMR is a valid alternative to CEMR for treating LNPCLs and could be considered the first option of treatment for lesions between 20 and 30 mm due to its higher en bloc and R0 resection rates. (Clinical trial registration number: NCT03567746.).

Endoscopy-Related Bleeding and Thromboembolic Events in Patients on Direct Oral Anticoagulants or Vitamin K Antagonists.

BACKGROUND & AIMS: Few prospective studies have assessed the safety of direct oral anticoagulants (DOACs) in elective endoscopy. Our primary aim was to compare the risks of endoscopy-related gastrointestinal bleeding and thromboembolic events in patients on DOACs or vitamin K antagonists (VKAs) in this setting. Secondarily, we examined the impact of the timing of anticoagulant resumption on the risk of delayed bleeding in high-risk therapeutic procedures. METHODS: We conducted a multicenter, prospective, observational study from January 2018 to March 2020 of 1602 patients on oral anticoagulants (1004 on VKAs and 598 on DOACs) undergoing 1874 elective endoscopic procedures. Our primary outcomes were 90-day thromboembolic events and 30-day endoscopy-related gastrointestinal bleeding. The inverse probability of treatment weighting propensity score method was used for baseline covariate adjustment. RESULTS: The 2 groups had similar risks of endoscopy-related gastrointestinal bleeding (VKAs vs DOACs, 6.2% vs 6.7%; adjusted odds ratio [OR], 1.05; 95% CI, 0.67-1.65) and thromboembolic events (VKAs vs DOACs, 1.3% vs 1.5%; adjusted OR, 0.90; 95% CI, 0.34-2.38). In high bleeding risk procedures (n = 747), delayed anticoagulant resumption (> 48 hours or 24-48 hours vs < 24 hours) did not reduce the risk of postprocedural bleeding (10.3%, 9%, and 5.8%, respectively; adjusted P = .43). Hot and cold snare polypectomy were the most frequent high-risk interventions (41.8% and 39.8%, respectively). CONCLUSION: In a prospective study of patients on DOACs or VKAs undergoing elective endoscopy, endoscopy-related bleeding and thromboembolic events showed similar risk. Our study suggests that early anticoagulant resumption is safe in most patients, but more data are needed for advanced high-risk therapeutic procedures.

Findings in the distal and proximal colon in colonoscopy screening after positive FIT and related pre-procedure factors.

BACKGROUND: Colonoscopy is the gold standard method for the early diagnosis and prevention of colorectal cancer (CRC). Screening programs include immune determination of blood in feces. Regardless of the method used, proximal colon lesions appear to be detected less frequently. OBJECTIVE: Analyze the characteristics of proximal and distal lesions and possible predisposing factors. METHODS: A cross-sectional study was performed of 692 patients from the CRC screening program with FIT ≥ 100ngHb/ml (October 2017 - October 2018). The right colon was examined twice as patients were participating in a randomized clinical trial to re-evaluate the right colon by forward-viewing endoscope or proximal retroflexion. The adenoma detection rate (ADR), advanced neoplasia (AN) and CRC in the proximal and distal colon, the histological and morphological characteristics in each section were analyzed. RESULTS: 52.9% of the patients were male, with a mean age of 59.5 years (SD: 7.6). 1490 polyps were found and the ADR was 57.7% (distal 42% and proximal 37%). Detection rates were 45.8% for AN, 40.9% for advanced adenomas, 5.2% for advanced SSL and CRC was diagnosed in 4.8% of patients. Males had more AN than females. The mean age of patients with AN was significantly higher. AN were associated with smoking and alcohol consumption (p=0.0001). Globally, FIT levels were higher in patients with AN (p=0.003). Sixty-six per cent of cancers were distally located and 61.3% of CRC were diagnosed in the early stages. CONCLUSIONS: In an average-risk asymptomatic population undergoing colonoscopy after positive FIT, AN were more common in the distal colon in males, older patients, smokers and those with alcohol intake.

Narrow-band imaging and high-definition white-light endoscopy in patients with serrated lesions not fulfilling criteria for serrated polyposis syndrome: a randomized controlled trial with tandem colonoscopy.

BACKGROUND: It is unknown whether narrow-band imaging (NBI) could be more effective than high-definition white-light endoscopy (HD-WLE) in detecting serrated lesions in patients with prior serrated lesions > 5 mm not completely fulfilling serrated polyposis syndrome (SPS) criteria. METHODS: We conducted a randomized, cross-over trial in consecutive patients with prior detection of at least one serrated polyp ≥10 mm or ≥ 3 serrated polyps larger than 5 mm, both proximal to the sigmoid colon. Five experienced endoscopists performed same-day tandem colonoscopies, with the order being randomized 1:1 to NBI-HD-WLE or HD-WLE-NBI. All tandem colonoscopies were performed by the same endoscopist. RESULTS: We included 41 patients. Baseline characteristics were similar in the two cohorts: NBI-HD-WLE (n = 21) and HD-WLE-NBI (n = 20). No differences were observed in the serrated lesion detection rate of NBI versus HD-WLE: 47.4% versus 51.9% (OR 0.84, 95% CI: 0.37-1.91) for the first and second withdrawal, respectively. Equally, no differences were found in the polyp miss rate of NBI versus HD-WLE: 21.3% versus 26.1% (OR 0.77, 95% CI: 0.43-1.38). Follow-up colonoscopy in nine patients (22%) allowed them to be reclassified as having SPS. CONCLUSIONS: In patients with previous serrated lesions, the serrated lesion detection rate was similar with NBI and HD-WLE. A shorter surveillance colonoscopy interval increases the detection of missed serrated polyps and could change the diagnosis of SPS in approximately one in every five patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT02406547, registered on April 2, 2015.

Panchromoendoscopy Increases Detection of Polyps in Patients With Serrated Polyposis Syndrome.

BACKGROUND & AIMS: Serrated polyposis syndrome (SPS), characterized by multiple and/or large proximal serrated lesions, increases the risk of colorectal cancer. Serrated lesions often are missed during colonoscopy but panchromoendoscopy can increase their detection in an average-risk population. We performed a randomized controlled study to determine the efficacy of panchromoendoscopy in detection of polyps in patients with SPS. METHODS: Patients with SPS (n = 86 patients) underwent tandem high-definition (HD) colonoscopies from February 2015 through July 2016 at 7 centers in Spain. Patients were assigned randomly to groups that received 2 HD white-light endoscopy examinations (HD-WLE group; n = 43) or HD-WLE followed by 0.4% indigo carmine panchromoendoscopy (HD-CE group; n = 43). For each procedure, polyps detected were described, removed, and analyzed by histology. The primary outcome was additional polyp detection rate, defined as the number of polyps detected during the second inspection divided by the total number of polyps detected during the first and the second examination. RESULTS: A total of 774 polyps were detected (362 in the HD-WLE group and 412 in the HD-CE group); 54.2% were hyperplastic, 13.8% were adenomas, and 10.9% were sessile serrated polyps. There was a significantly higher additional polyp detection rate in the HD-CE group (0.39; 95% CI, 0.35-0.44) than in the HD-WLE group (0.22; 95% CI, 0.18-0.27) (P < .001). A higher additional rate of serrated lesions proximal to the sigmoid colon were detected in the second inspection with HD-CE (0.40; 95% CI, 0.33-0.47) than with HD-WLE (0.24; 95% CI, 0.19-0.31) (P = .001). Detection of adenomas and serrated lesions greater than 10 mm did not differ significantly between groups. In a multivariate logistic regression analysis, only use of HD-CE was associated independently with increased polyp detection throughout the colon. CONCLUSIONS: In a randomized controlled trial, we found that panchromoendoscopy increases detection of polyps (mostly of small serrated lesions) and should be considered the standard of care in patients with SPS. Studies are needed to determine the effects of this strategy on the incidence of advanced neoplasia during long-term follow-up evaluation. ClinicalTrials.gov no: NCT03476434.

Proximal retroflexion versus second forward view of the right colon during screening colonoscopy: A multicentre randomized controlled trial.

BACKGROUND: Colonoscopy is the gold standard investigation for the detection of colorectal cancer, but the right colon is more difficult to examine than the left colon. A second examination of the proximal colon has the potential to reduce rates of missed pathology. OBJECTIVE: To determine whether proximal retroflexion improves the adenoma detection rate or other outcomes in the right colon compared with the forward view. METHODS: We performed a multicentre randomized controlled trial of patients from the colorectal cancer screening programme with a positive faecal immunochemical test. Patients were randomized to a second right colon examination using proximal retroflexion or forward view. RESULTS: A total of 692 patients were included. A second examination of the right colon, with an average additional procedure time of 1.62 min, increased the adenoma detection rate by 11%, regardless of the method used (9% proximal retroflexion vs. 12% second forward view, p = 0.21). The adenoma miss rate was 19% (17% proximal retroflexion vs. 20% forward view, p = 0.28) The success rate of retroflexion was 83%, without secondary complications. In the 15.6% of patients in whom lesions were detected during the second pass, endoscopic follow-up was modified by reducing the time of the next colonoscopy. CONCLUSIONS: A second examination of the right colon, either from retroflexion or second forward view, can increase adenoma detection rate and shorten surveillance intervals in patients undergoing screening colonoscopy. This should be emphasized during colonoscopy training and integrated into diagnostic colonoscopy practice.

Narrow band imaging and white light endoscopy in the characterization of a polypectomy scar: A single-blind observational study.

AIM: To assess the incremental benefit of narrow band imaging (NBI) and white light endoscopy (WLE), randomizing the initial technique for the detection of residual neoplasia at the polypectomy scar after an endoscopic piecemeal mucosal resection (EPMR). METHODS: We conducted an observational study in an academic center to assess the incremental benefit of NBI and WLE randomly applied 1:1 (NBI-WLE or WLE-NBI) in the follow-up of a post-EPMR scar by the same endoscopist. RESULTS: A total of 112 EPMR scars were included. The median baseline polyp size was 20 mm (interquartile range: 14-30). At first review, NBI and WLE showed good sensitivity (85.0% vs 78.9%), specificity (77.1% vs 84.2%) and overall accuracy (80.0% vs 82.5%). NBI after WLE (WLE-NBI group) improved accuracy, but this difference was not statistically significant [area under the curve (AUC): 86.8% vs 81.6%, P = 0.15]. WLE after NBI (NBI-WLE group) did not improve accuracy (AUC: 81.4% vs 81.1%, P = 0.9). Overall, recurrence was found in 39/112 (34.8%) lesions. CONCLUSION: Although no statistically significant differences were found between the two techniques at the first post-EPMR assessment, the use of NBI after WLE may improve residual neoplasia detection. Nevertheless, biopsy is still required in the first scar review.

Findings in the distal and proximal colon in colonoscopy screening after positive FIT and related pre-procedure factors

Background: colonoscopy is the gold standard method forthe early diagnosis and prevention of colorectal cancer(CRC). Screening programs include immune determinationof blood in feces. Regardless of the method used, proximalcolon lesions appear to be detected less frequently.Objective: to analyze the characteristics of proximal anddistal lesions and possible predisposing factors.Methods: a cross-sectional study was performed of 692patients from the CRC screening program with fecal immunological test (FIT) ≥ 100 ngHb/ml (October 2017-October2018). The right colon was examined twice as patients wereparticipating in a randomized clinical trial to re-evaluatethe right colon by forward-viewing endoscope or proximalretroflexion. The adenoma detection rate (ADR), advancedneoplasia (AN) and CRC in the proximal and distal colon,histological and morphological characteristics in each section were analyzed.Results: in the study, 52.9 % of the patients were male, witha mean age of 59.5 years (standard deviation [SD]: 7.6);1,490 polyps were found and the ADR was 57.7 % (distal42 % and proximal 37 %). Detection rates were 45.8 % forAN, 40.9 % for advanced adenomas, 5.2 % for advancedsessile serrated lesions (SSL) and CRC was diagnosed in4.8 % of patients. Males had more AN than females. Themean age of patients with AN was significantly higher. ANwere associated with smoking and alcohol consumption (p = 0.0001). Globally, FIT levels were higher in patientswith AN (p = 0.003). Sixty-six per cent of cancers were distally located and 61.3 % of CRC were diagnosed in the earlystages.Conclusions: in an average-risk asymptomatic populationundergoing colonoscopy after positive FIT, AN were morecommon in the distal colon in males, older patients, smokers and those with alcohol intake. (AU)