Diagnosis of sessile serrated adenomas/polyps with image-enhanced endoscopy: a systematic review and meta-analysis.

BACKGROUND AND STUDY AIMS: Distinguishing sessile serrated adenomas/polyps (SSA/Ps) from non-neoplastic tissue may be challenging when white-light endoscopy (WLE) is used. Image-enhanced endoscopy (IEE) has shown accuracy in differentiating adenomas from hyperplastic polyps. The aim of this systematic review and meta-analysis was to evaluate the utility of IEE in diagnosis of SSA/Ps. METHODS: Studies were eligible if: they included patients undergoing colonoscopy with an endoscopy-based image-enhancement modality; endoscopic diagnoses, including SSA/P, were based on the appearance of polyps at IEE; and the corresponding histologic diagnoses of polyps were provided. The primary outcome was sensitivity of IEE for SSA/Ps differentiated from non-neoplastic lesions (primary convention) and differentiated from all non-SSA/P lesions, including adenomas (secondary convention). RESULTS: 13 studies met inclusion criteria. Sensitivity ranged from 38 % to 100 % but sensitivity ≥ 90 % was seen in 4 of 10 narrow band imaging (NBI) or magnification-NBI studies. Pooled sensitivities for discriminating SSA/Ps from non-neoplastic lesions were 80 % for magnification-NBI, 60 % for NBI, 49 % for autofluorescence, and 47 % for flexible spectral imaging color enhancement. In head-to-head comparisons with WLE, NBI (89 % vs. 75 %) and magnification-NBI (78 % vs. 63 %) demonstrated significantly greater sensitivity, while autofluorescence imaging (56 % vs. 66 %), flexible spectral imaging color enhancement (100 % vs. 100 %), and high-resolution endomicroscopy (88 % vs. 100 %) did not. CONCLUSION: IEE currently cannot be recommended as a diagnostic tool for SSA/P. While NBI studies showed promise, more IEE studies employing validated SSA/P criteria in well-defined polyp populations are needed. IEE studies assessing SSA/P detection rates at colonoscopy are also needed.

Can I improve my adenoma detection rate?

Adenoma detection rate (ADR) has emerged as a key quality metric for colonoscopy. Despite limitations, its major strength is based on its proven correlation with interval colorectal cancer. This has prompted extensive efforts to identify factors and interventions that improve ADR. Potentially modifiable factors that may influence ADR can be patient related (eg, bowel preparation), endoscopist related (eg, withdrawal time, quality of mucosal inspection, additional observers), or procedure related (eg, water infusion, additional examination of right colon, change in position, antispasmodics, colonoscopic equipment, and accessories). Providing endoscopists with educational material and/or feedback also seems to improve ADR.

Variation in polyp size estimation among endoscopists and impact on surveillance intervals.

BACKGROUND: Accurate estimation of polyp size is important because it is used to determine the surveillance interval after polypectomy. OBJECTIVE: To evaluate the variation and accuracy in polyp size estimation among endoscopists and the impact on surveillance intervals after polypectomy. DESIGN: Web-based survey. PARTICIPANTS: A total of 873 members of the American Society for Gastrointestinal Endoscopy. INTERVENTIONS: Participants watched video recordings of 4 polypectomies and were asked to estimate the polyp sizes. MAIN OUTCOME MEASUREMENTS: Proportion of participants with polyp size estimates within 20% of the correct measurement and the frequency of incorrect surveillance intervals based on inaccurate size estimates. RESULTS: Polyp size estimates were within 20% of the correct value for 1362 (48%) of 2812 estimates (range 39%-59% for the 4 polyps). Polyp size was overestimated by >20% in 889 estimates (32%, range 15%-49%) and underestimated by >20% in 561 (20%, range 4%-46%) estimates. Incorrect surveillance intervals because of overestimation or underestimation occurred in 272 (10%) of the 2812 estimates (range 5%-14%). Participants in a private practice setting overestimated the size of 3 or of all 4 polyps by >20% more often than participants in an academic setting (difference = 7%; 95% confidence interval, 1%-11%). LIMITATIONS: Survey design with the use of video clips. CONCLUSION: Substantial overestimation and underestimation of polyp size occurs with visual estimation leading to incorrect surveillance intervals in 10% of cases. Our findings support routine use of measurement tools to improve polyp size estimates.

Sublingual hyoscyamine spray as premedication for colonoscopy: a randomized double-blinded placebo-controlled trial.

BACKGROUND: Colonic motility and spasm during colonoscopy may affect duration and quality of the examination as well as patient comfort during and after the procedure. Previous studies assessing the utility of antispasmodic agents in colonoscopy demonstrated conflicting results. The aim of this study was to determine the effect of sublingual hyoscyamine spray (IB-Stat, Inkine Pharmaceutical) on the performance of colonoscopy. METHODS: One hundred patients undergoing elective colonoscopy were randomized in a double-blind study to receive .25 mg sublingual hyoscyamine spray (n = 50: 25 men and 25 women, mean age 60) or placebo spray (n = 50: 23 men and 27 women, mean age 56) 15 to 30 minutes before the procedure. Parameters measured included time required to reach the cecum, total procedure time, endoscopist perception of colonic motility and difficulty of the procedure, and patient assessment of discomfort after the procedure. The latter parameters were measured using a 100-mm visual analog scale. A single endoscopist performed all of the procedures. RESULTS: After adjustment for age, procedural difficulty scores and colonic motility scores were significantly lower in the hyoscyamine group compared with placebo (differences of 5.589 mm [P = .047] and 5.685 mm [P = .040], respectively). Mean time to cecal intubation and percentage of patients with discomfort were slightly lower in the hyoscyamine group (5.68 minutes/48%) compared with placebo (5.92 minutes/57.1%), although the differences were not statistically significant (P = .57 and P = .36, respectively). CONCLUSIONS: Procedural difficulty and colonic motility scores were significantly lower in subjects who received sublingual hyoscyamine before colonoscopy.

Neuroendocrine regulation of food intake.

PURPOSE OF REVIEW: The majority of adults in many developed countries are overweight or obese. The obesity epidemic is also affecting children worldwide. Obesity increases the risk of several diseases leading to life-threatening complications. Weight regulation depends on food intake (energy intake) and energy expenditure. The purpose of this review is to provide updated information on the neuroendocrine regulation of food intake and energy homeostasis. RECENT FINDINGS: New knowledge about the role of the prefrontal cortex in the regulation of food intake has emerged. The pathways responsible for energy homeostasis are now increasingly being understood, and as a consequence, an increasing number of pharmacologic agents targeting these pathways are being actively developed. Emphasis on the concept of long-term (as opposed to short-term) homeostasis has guided the search for therapeutic molecules or combination of molecules that would inhibit food intake constantly and thus lead to maintained weight loss. SUMMARY: Complex and intricate neuroendocrine pathways control food intake and energy homeostasis. The increasing understanding of the different components orchestrating the regulation of food intake provides new and exciting targets for much needed pharmacotherapy for obesity.