Back-to-Back Comparison of Colonoscopy With Virtual Chromoendoscopy Using a Third-Generation Narrow-Band Imaging System to Chromoendoscopy With Indigo Carmine in Patients With Lynch Syndrome.

INTRODUCTION: Colonoscopic screening with indigo carmine chromoendoscopy (ICC) in patients with Lynch syndrome (LS) improves the adenoma detection rate but is time consuming and poorly used in clinical practice. Narrow-band imaging (NBI), a virtual chromoendoscopy technique, highlights superficial mucosal vessels and improves adenoma characterization. We conducted a prospective multicenter trial in a back-to-back fashion to compare the third-generation NBI with ICC for detecting colonic adenomas in patients with LS. METHODS: In a multicenter, prospective, noninferiority trial, 138 patients underwent a double colonoscopy, first with NBI, followed by ICC, in a back-to-back design. The primary noninferiority outcome measure was the number of patients with at least one adenoma after NBI compared with the number of patients with at least one adenoma after NBI and ICC. RESULTS: The 138 analyzable patients were all proven mismatch repair mutation carriers for LS (MLH1 = 33%, MSH2 = 47%, MSH6 = 15%, PMS2 = 4%, and EPCAM = 1%). The mean age (SD) was 40.5 (14.7) years, and 64 (46.4%) were men. The median withdrawal time for an NBI procedure was 8 minutes (interquartile range 6-11) compared with 13 minutes (interquartile range 8-17) for ICC. At least one adenoma was detected during the initial NBI pass in 28 patients (20.3%), and 42 patients (30.4%) had at least one adenoma detected after both NBI and ICC (difference, 10.1%; 95% confidence interval, -0.1%-20.3%); this represents an increase of 50.0% of the adenoma detection rate. ICC detected additional adenomas in 25 patients (18.1%). DISCUSSION: Colonoscopy combining NBI and ICC detects more adenomas than third-generation NBI alone in patients with LS, respectively, 30.4% vs 20.3% (difference, 10.1%; 95% confidence interval, -0.1 to 20.3), thus failing the noninferiority assumption of NBI compared with combined NBI and ICC. Although less time consuming, colonoscopy using the third-generation NBI cannot be recommended to replace ICC in patients with LS.

Impact of an optimized colonoscopic screening program for patients with Lynch syndrome: 6-year results of a specialized French network.

BACKGROUND: Despite colonoscopic screening, colorectal cancer (CRC) remains frequent in patients with Lynch syndrome (LS). The objective of this study was to evaluate the impact of an optimized colorectal screening program within a French dedicated network. METHODS: All LS patients followed at our institution were consecutively included in the Prédisposition au Cancer Colorectal-Ile de France (PRED-IdF) network. Patients were offered an optimized screening program allowing an adjustment of the interval between colonoscopies, depending on bowel preparation, chromoendoscopy achievement and adenoma detection. Colonoscopies were defined as optimal when all the screening criteria were respected. We compared colonoscopy quality and colonoscopy detection rate before and after PRED-IdF inclusion, including polyp detection rate (PDR), adenoma detection rate (ADR) and cancer detection rate (CDR). RESULTS: Between January 2010 and January 2016, 144 LS patients were consecutively included (male/female = 50/94, mean age = 51 ± 13 years and mutations: MLH1 = 39%, MSH2 = 44%, MSH6 = 15%, PMS2 = 1%). A total of 564 colonoscopies were analyzed, 353 after inclusion and 211 before. After PRED-IdF inclusion, 98/144 (68%) patients had optimal screening colonoscopies versus 33/132 (25%) before (p < 0.0005). The optimal colonoscopy rate was 304/353 (86%) after inclusion versus 87/211 (41%) before, (p < 0.0001). PRED-IdF inclusion was associated with a reduction of CRC occurrence with a CDR of 1/353 (0.3%) after inclusion versus 6/211 (2.8%) before (p = 0.012). ADR and PDR were 99/353 (28%) versus 60/211 (28.8%) (p > 0.05) and 167/353 (48.1%) versus 90/211 (42.2%) (p > 0.05), respectively after and before inclusion. CONCLUSIONS: An optimized colonoscopic surveillance program in LS patients seems to improve colonoscopic screening quality and might possibly decrease colorectal interval cancer occurrence. Long-term cohort studies are needed to confirm these results.

Real-world use of idarucizumab for dabigatran reversal in three cases of serious bleeding.

Bleeding is a rare complication of direct oral anticoagulant potentially associated with high mortality rates. Biological monitoring is necessary for more than 24 h after idarucizumab antidote therapy in case of bleeding with dabigatran therapy.

Seven cases of upper gastrointestinal bleeding after cold biopsy.

BACKGROUND AND STUDY AIMS: Routine biopsy of the upper gastrointestinal tract is performed with increasing frequency. It is generally considered to be safe without significant complication. However, gastrointestinal bleeding as a result of cold biopsy is a known complication. We report seven cases of upper gastrointestinal bleeding after cold biopsy and discuss clinical data, risks factors, severity and management of this event. We suggest that physicians must be more cautious with this rare but potentially severe complication.

Small bowel polypectomy by double balloon enteroscopy: Correlation with prior capsule endoscopy.

AIM: To investigate the feasibility of small bowel polypectomy using double balloon enteroscopy and to evaluate the correlation with capsule endoscopy (CE). METHODS: This is a retrospective review of a single tertiary hospital. Twenty-five patients treated by enteroscopy for small bowel polyps diagnosed by CE or other imaging techniques were included. The correlation between CE and enteroscopy (correlation coefficient of Kendall for the number of polyps, intra-class coefficient for the size and coefficient of correlation kappa for the location) was evaluated. RESULTS: There were 31 polypectomies and 12 endoscopic mucosal resections with limited morbidity and no mortality. Histological analysis revealed 27 hamartomas, 6 adenomas and 3 lipomas. Strong agreement between CE and optical enteroscopy was observed for both location (Kappa value: 0.90) and polyp size (Kappa value: 0.76), but only moderate agreement was found for the number of polyps (Kendall value: 0.47). CONCLUSION: Double balloon enteroscopy is safe for performing polypectomy. Previous CE is useful in selecting the endoscopic approach and to predicting the difficulty of the procedure.

Multicenter comparison of double-balloon enteroscopy and spiral enteroscopy.

BACKGROUND AND AIM: Spiral enteroscopy is a novel technique for small bowel exploration. The aim of this study is to compare double-balloon and spiral enteroscopy in patients with suspected small bowel lesions. METHODS: Patients with suspected small bowel lesion diagnosed by capsule endoscopy were prospectively included between September 2009 and December 2010 in five tertiary-care academic medical centers. RESULTS: After capsule endoscopy, 191 double-balloon enteroscopy and 50 spiral enteroscopies were performed. Indications were obscure gastrointestinal bleeding in 194 (80%) of cases. Lesions detected by capsule endoscopy were mainly angioectasia. Double-balloon and spiral enteroscopy resulted in finding one or more lesions in 70% and 75% of cases, respectively. The mean diagnosis procedure time and the average small bowel explored length during double-balloon and spiral enteroscopy were, respectively, 60 min (45-80) and 55 min (45-80) (P=0.74), and 200 cm (150-300) and 220 cm (200-300) (P=0.13). Treatment during double-balloon and spiral enteroscopy was possible in 66% and 70% of cases, respectively. There was no significant major procedure-related complication. CONCLUSION: Spiral enteroscopy appears as safe as double-balloon enteroscopy for small bowel exploration with a similar diagnostic and therapeutic yield. Comparison between the two procedures in terms of duration and length of small bowel explored is slightly in favor of spiral enteroscopy but not significantly.

Phlegmonous gastritis in a 32-week pregnant woman managed by conservative surgical treatment and antibiotics.

Phlegmonous gastritis is an extremely rare and life-threatening condition. We report the case of a 32-week pregnant women presenting a peritonitis owing to phlegmonous gastritis caused by a group A streptococcus and successfully managed by conservative surgical treatment and antibiotics. Multiple endoscopies with biopsies illustrate progressive and complete gastric recovery.