Bite-on-bite biopsies for the detection of residual esophageal cancer after neoadjuvant chemoradiotherapy.

BACKGROUND: Active surveillance after neoadjuvant treatment is increasingly implemented. The success of this strategy relies on the accurate detection of residual cancer. This study aimed to assess the diagnostic value of a second (bite-on-bite) biopsy for the detection of residual esophageal cancer and to correlate outcomes to the distribution of residual cancer found in the resection specimen. METHODS: A multicenter prospective study of esophageal cancer patients undergoing active surveillance after neoadjuvant chemoradiotherapy was performed. At clinical response evaluations, an upper gastrointestinal (GI) endoscopy was performed with at least four bite-on-bite biopsies of the primary tumor site. First and second biopsies were analyzed separately. Patients with histopathological evidence of residual cancer were included in the primary analysis. Two pathologists blinded for biopsy outcome examined all resection specimens. RESULTS: Between October 2017 and July 2020, 626 upper GI endoscopies were performed in 367 patients. Of 138 patients with residual cancer, 112 patients (81 %) had at least one positive biopsy. In 14 patients (10 %) only the first biopsy was positive and in 25 patients (18 %) only the second biopsy (P = 0.11). Remarkably, the rates of patients with tumor-free mucosa and deeper located tumors were higher in patients detected by the first biopsy. The second biopsy increased the false-positive rate by 3 percentage points. No adverse events occurred. CONCLUSIONS: A second (bite-on-bite) biopsy improves the detection of residual esophageal cancer by almost 20 percentage points, at the expense of increasing the false-positive rate by 3 percentage points. The higher detection rate is explained by the higher number of biopsies obtained rather than by the penetration depth.

Low-volume PEG plus ascorbic acid versus high-volume PEG as bowel preparation for colonoscopy.

OBJECTIVE: High volumes of polyethylene glycol (PEG)-based solutions as bowel preparation for colonoscopy are effective, but often poorly tolerated. To compare a 2 l PEG-based solution combined with ascorbic acid (PEG + Asc) with 4 l PEG-based solution (PEG). METHODS: In a single blind, quasi-randomized, prospective study, 350 patients undergoing colonoscopy received 2 l of PEG + Asc or 4 l of PEG. For morning procedures, the total dose of PEG + Asc was taken the evening before, for afternoon colonoscopies, PEG + Asc was given as a split dose. The 4 l PEG preparation was given as a split dose. Efficacy of preparation was scored on a five-point scale in three different colon segments. Patients' experiences were evaluated using a questionnaire. RESULTS: From 307 patients (149 PEG + Asc, 158 PEG), results were available. Successful colon cleansing was achieved in 90.6% in the PEG + Asc group compared to 96% in the PEG group (not significant). In patients prepared with PEG + Asc, bowel cleansing was worse when patients underwent colonoscopy in the morning, compared to afternoon procedures. Side-effects and patients' experiences were similar in the PEG + Asc and PEG group. CONCLUSIONS: Low-volume PEG + ascorbic acid has comparable efficacy and tolerability as high-volume PEG solution. The cleansing results were worse if patients received the full dose PEG + Asc the evening before the procedure compared to the split dose. Our data support the administration of PEG + Asc as a split dose before the procedure.

Diffuse enteritis after colectomy for ulcerative colitis: two case reports and review of the literature.

Ulcerative colitis (UC) is an inflammatory disease of the colon. Involvement of the small bowel is limited to backwash ileitis or pouch-related conditions. Here, we report two men with UC who presented with small bowel inflammation and even perforation, within 1 month after subtotal colectomy. Endoscopy showed diffuse enteritis. Histology showed marked apoptosis of epithelial cells in both cases. One patient responded to steroids and the other to a calcineurin inhibitor. Both patients had no evidence of Crohn's disease in the small intestine before this event. Several more cases of small intestinal lesions in patients with well-established UC have been reported. The majority typically presented shortly after colectomy and responded well to steroids. The pathogenesis of this enteritis is unknown, but seems to be distinct from Crohn's disease and may be associated with UC and colectomy.

Colonoscopy training for nurse endoscopists: a feasibility study.

BACKGROUND: Screening by using colonoscopy is recommended in many countries to reduce the risk of death from colorectal cancer. Given the limited supply of medical endoscopists, nurse endoscopists may represent an economic alternative. OBJECTIVE: To develop a colonoscopy training program for nurse endoscopists and to evaluate the feasibility of this program. DESIGN: Two nurse endoscopists and 1 first-year GI fellow were enrolled in a colonoscopy training protocol, including computer-simulator training, flexible sigmoidoscopies, and colonoscopies under direct supervision. SETTING: A single-center prospective study. PATIENTS: The first 150 complete colonoscopies of each trainee endoscopist were evaluated and compared with 150 colonoscopies performed by an experienced endoscopist. MAIN OUTCOME MEASUREMENTS: Objective criteria for competency were diagnostic accuracy, cecal-intubation rate, cecal-intubation time, the need for assistance, and complications. Subjective criteria included patient satisfaction, pain, and discomfort scores. RESULTS: The nurse endoscopists' unassisted cecal-intubation rate was 80% for the first 25 procedures, gradually increasing in subsequent cases to 96% for the last 25 procedures. The mean cecal-intubation time at the end of the training period was 10 minutes. Cecal-intubation rates and times were comparable between the nurse trainees and the fellow. The patients reported low degrees of pain and discomfort, and high satisfaction scores, irrespective of the type of endoscopist. Diagnostic accuracy of the trainees was good. The complication rate was 0.3%. LIMITATION: Nonrandomized design. CONCLUSIONS: This pilot study suggests that nurses can be trained to perform colonoscopy in an effective manner, with results similar to a GI fellow. The learning curve indicated that 150 procedures are required before independent examinations are attempted.