Preparation Regimens to Improve Capsule Endoscopy visualization and diagnostic yield (PrepRICE); a multicentric randomized trial.

BACKGROUND AND AIMS: Current guidelines recommend bowel preparation before small-bowel capsule endoscopy (SBCE). However, the optimal protocol is yet to be defined. To determine the best timing for preparation in SBCE, we compared small-bowel visualization quality (SBVQ), diagnostic yield (DY), and patient-reported outcomes across four purgative regimens. METHODS: In this prospective, randomized (1:1:1:1), multicentric study, patients with suspected small bowel bleeding were randomized into four arms: G1 (1L of polyethylene-glycol + ascorbic acid [Moviprep®] the night before SBCE), G2 (1L in the morning, up to 2 hours before SBCE), G3 (0.5L up to 2 hours before + 0.5L after the capsule reached the duodenum), and G4 (1L after reaching the duodenum). To assess DY, lesions were categorized as having high (P2) or low (P0 or P1) bleeding potential. Small-bowel visualization quality (SBVQ) was assessed using the Brotz score. Transit times (TT) were measured, and patient tolerability was scored from 0 to 5 with higher scores indicating better tolerability. RESULTS: A total of 387 patients were included; 59% female with a median age of 73 years (IQR 23). The exam completion rate was lower in G1 (90%, p<0.001). Small bowel TT was shorter for patients receiving purgative during SBCE (G3 and G4, p=0.001). SBVQ was better in patients receiving purgative after reaching the SB (p<0.001): median of 7 for G1, 8 for G2, and 9 for G3 and G4. The overall DY of patients receiving intra-procedure purgatives (G3 + G4) was superior (42.7 vs 31.3%, p=0.02); significant differences were found in the second and third terciles. Likewise, G3 and G4 had higher angioectasia detection (p=0.04). Patients' satisfaction was significantly superior for G4 (median 4 points, IQR 1). CONCLUSIONS: The group that received the bowel preparation the night before SBCE had poorer outcomes. Intra-procedure purgative regimens reduced SBTT, enhanced visualization, improved DY, and increased angioectasia detection. G4 was the best-tolerated regimen.

Small-Bowel Angioectasias: Are They Responsible for a Real Impact on Survival?

Introduction: This study aimed to evaluate the effect of small-bowel angioectasia on survival, given the hypothesis that angioectasia might be an independent risk factor of frailty and poor outcomes. Methods: In this retrospective cohort study, all patients undergoing small-bowel capsule endoscopy between 2010 and 2013 for obscure gastrointestinal bleeding from a Portuguese tertiary centre were included. Follow-up started after capsule endoscopy and ended upon death or end of the study (November 2020). Survival analysis was performed using a Cox proportional-hazards model, in order to analyse the effect of small-bowel angioectasia on survival as well as potentially confounding factors (age, vascular diseases and chronic kidney disease). Results: A total of 176 patients were included in this study (50.6% male), with a median age of 68.5 years (IQR 24). The median follow-up was 7 years (IQR 4), during which 67 (38.1%) patients died. Seventy-three (41.5%) patients had at least one small-bowel angioectasia on capsule endoscopy. On multivariate Cox regression analysis, only age, peripheral arterial disease, history of previous mesenteric ischaemia and chronic kidney disease were independent risk factors of death. The presence of small-bowel angioectasia did not affect survival in this analysis (HR 1.30; 95% CI 0.75-2.23; p = 0.35). Conclusion: In this retrospective cohort study, some comorbidities and age were independent predictors of poor survival. The presence of small-bowel angioectasia per se did not affect survival.

Introdução: Este estudo pretendeu avaliar a influência das angiectasias do intestino delgado na sobrevida, dada a hipótese de que as angiectasias pudessem constituir um fator de risco independente para fragilidade e outcomes adversos. Métodos: Os autores incluíram neste estudo de coorte retrospetivo todos os doentes submetidos a cápsula endoscópica entre 2010 e 2013 por hemorragia digestiva obscura num centro português terciário. O followup iniciou-se após a realização da cápsula e terminou aquando da morte ou fim do estudo (Novembro de 2020). A análise da sobrevida foi realizada através de um modelo de regressão de Cox, no sentido de analisar o efeito na sobrevida das angiectasias do intestino delgado e de potenciais fatores confundidores (idade, doenças vasculares e doença renal crónica). Resultados: Neste estudo foram incluídos 176 doentes (50.6% do sexo masculino), com uma idade mediana de 68.5 anos (IQR 24). O tempo de follow-up mediano foi de 7 anos (IQR 4), durante o qual se verificaram 67 (38.1%) óbitos. 73 (41.5%) dos doentes apresentavam pelo menos uma angiectasia no intestino delgado. Na análise de sobrevida, apenas a idade, doença arterial periférica, história prévia de isquemia mesentérica e doença renal crónica foram fatores de risco independentes de mortalidade. A presença de angiectasias no intestino delgado não afetou a sobrevida nesta amostra (HR 1,30; 95% CI 0,75­2,23; p = 0.35). Conclusão: Neste estudo de coorte retrospetivo, algumas co-morbilidades e a idade foram fatores de risco independentes de mortalidade. A presença de angiectasias no intestino delgado, per se, não afetou a sobrevida.

Capsule Enteroscopy Using the Mirocam® versus OMOM® Systems: A Matched Case-Control Study.

Although several devices are available for small bowel capsule endoscopy, few studies have compared their visualization quality and diagnostic yield, despite users reporting subjective differences between them. This study aims to compare two widely used systems (Mirocam® MC1600 and OMOM® HD). Patients who underwent OMOM® HD capsule enteroscopy between August 2022 and February 2023 were prospectively included consecutively (cases). Controls were retrospectively selected from a database of patients who underwent Mirocam® MC1600 enteroscopy between March 2018 and July 2022 in a 1:1 ratio. Controls were matched for potential confounders (age, sex, indication, hospitalization, comorbidities, and opioid prescription). The small bowel cleanliness (global and divided by tertiles), the diagnostic yield (positive findings) and the transit times (TT) were compared. Overall, 214 patients were included (107:107). Global bowel preparation was similar between the OMOM® and Mirocam® groups. However, the average scores for each tertile were significantly higher when the OMOM® HD capsule was used (p < 0.05). Small bowel TT was shorter for OMOM® HD (265 ± 118 versus 307 ± 87 min, p = 0.020), while the diagnostic yield (55.0%) and relative distribution of lesions were similar. This study suggests that capsule characteristics, namely resolution, and illumination, systematically interfere with the perception of preparation quality. However, this did not affect the diagnostic yield.

Effective submucosal tunneling endoscopic resection (STER) of a giant esophageal leiomyoma.

We report the successful removal of a giant esophageal leiomyoma using submucosal tunneling endoscopic resection in a 37-year-old woman with significant dysphagia.

Multiple GIST and pheochromocytoma - A rare association in neurofibromatosis type 1.

We describe a case of coexistence of multiple gastrointestinal stromal tumors (GIST) and pheochromocytoma in a 32-year-old patient with neurofibromatosis type 1. The coexistence of these two conditions in patients with this syndrome is extremely rare.

Concordance of Dye-Spraying Chromoendoscopy and Virtual Chromoendoscopy for Colonic Dysplasia Detection in Longstanding Inflammatory Bowel Disease.

BACKGROUND/AIMS: In the past, dye-spraying chromoendoscopy was the technique of choice for colonic surveillance in patients with long-standing extensive inflammatory bowel disease. Recent evidence suggests that virtual chromoendoscopy is an equally acceptable technique. MATERIALS AND METHODS: Eleven gastroenterologists were given a survey with 20 pairs of pictures from inflammatory bowel disease surveillance colonoscopies (10 with nondysplastic lesions, 5 with dysplastic lesions, and 5 with no lesions). Each pair contained the same image captured during colonoscopy using indigo carmine and narrow-band imaging. For each picture, the gastroenterologist assessed the presence/absence of lesion and, when a lesion was identified, assessed the presence/absence of dysplasia and delineated its margins. To compare lesion and dysplasia detection between techniques, sensitivity, specificity, and interobserver agreement were calculated. The chi-square test was used to assess the accuracy of margins delineation. RESULTS: When assessing lesion and dysplasia detection, similar sensitivity and specificity values were obtained for both techniques. Interobserver agreement analysis revealed that dye-spraying chromoendoscopy and virtual chromoendoscopy had a moderate agreement in lesion detection but, for dysplasia detection, dye-spraying chromoendoscopy had a slight agreement [K = 0.11 (0.03-0.18), P < .01] and virtual chromoendoscopy a fair agreement [K = 0.30 (0.22-0.37), P < .01]. Margin delineation was similar between techniques. CONCLUSION: Sensitivity and specificity for lesion and dysplasia detection, as well as the accuracy of margins delineation, were similar between dye-spraying chromoendoscopy and virtual chromoendoscopy. Interobserver agreement for dysplasia detection was suboptimal in both techniques; however, it was superior when using virtual chromoendoscopy. These findings suggest that virtual chromoendoscopy constitutes a valid alternative for dysplasia screening in inflammatory bowel disease.

Predicting residual neoplasia after a non-curative gastric ESD: validation and modification of the eCura system in the Western setting: the W-eCura score.

OBJECTIVE: To evaluate the risk factors for lymph node metastasis (LNM) after a non-curative (NC) gastric endoscopic submucosal dissection (ESD) and to validate and eventually refine the eCura scoring system in the Western setting. Also, to assess the rate and risk factors for parietal residual disease. DESIGN: Retrospective multicentre multinational study of prospectively collected registries from 19 Western centres. Patients who had been submitted to surgery or had at least one follow-up endoscopy were included. The eCura system was applied to assess its accuracy in the Western setting, and a modified version was created according to the results (W-eCura score). The discriminative capacities of the eCura and W-eCura scores to predict LNM were assessed and compared. RESULTS: A total of 314 NC gastric ESDs were analysed (72% high-risk resection (HRR); 28% local-risk resection). Among HRR patients submitted to surgery, 25% had parietal disease and 15% had LNM in the surgical specimen. The risk of LNM was significantly different across the eCura groups (areas under the receiver operating characteristic curve (AUC-ROC) of 0.900 (95% CI 0.852 to 0.949)). The AUC-ROC of the W-eCura for LNM (0.916, 95% CI 0.870 to 0.961; p=0.012) was significantly higher compared with the original eCura. Positive vertical margin, lymphatic invasion and younger age were associated with a higher risk of parietal residual lesion in the surgical specimen. CONCLUSION: The eCura scoring system may be applied in Western countries to stratify the risk of LNM after a gastric HRR. A new score is proposed that may further decrease the number of unnecessary surgeries.

Tunneling-free peroral endoscopic septotomy for Zenker diverticulum.

Video 1Tunneling-free peroral endoscopic Zenker myotomy.

Critical Analysis of the Applicability of Small Bowel Capsule Endoscopy Performance Measures among 2 Portuguese Centers with Different Capsule Endoscopy Platforms.

Introduction: The European Society of Gastrointestinal Endoscopy (ESGE) identified the need to benchmark the quality of small bowel capsule endoscopy (SBCE) and produced a set of performance measures (PM). The aim of this study is to critically evaluate the accordance of the PM for SBCE in two Portuguese centers with different SBCE platforms. Methods: The authors conducted a cross-sectional analysis of consecutive SBCE performed in an 18-month period in 2 Portuguese centers that used two different SBCE platforms Mirocam® (IntroMedic, Seoul, South Korea) and PillCam® (Medtronic, Yokneam, Israel). A total of 10 PM (6 key, 4 minor) were evaluated and compared between the 2 centers. Results: A total of 493 SBCE were included. The minimum standard established by ESGE was reached in 3/6 key PM (complete visualization, lesion detection rate, and capsule retention rate), and none of the 4 minor PM. PM compliance significantly differed between the 2 centers: complete small bowel visualization 95.9 and 90% (p = 0.01), diagnostic yield 50.6 and 63% (p = 0.005), adequate small bowel cleansing level according to Brotz scale 69.54 and 84.6% (p ≤ 0.001), patients with high risk of capsule retention offered a patency capsule 4.2 and 73% (p ≤ 0.001), respectively. Conclusion: This study highlights and critically discusses technical and organizational issues that should be considered in defining more realistic PM thresholds, aiming to improve SBCE quality.

Introdução: A Sociedade Europeia de Endoscopia Digestiva (ESGE) identificou a necessidade de avaliar a qualidade da enteroscopia por videocápsula (EVC) e produziu um conjunto de medidas de desempenho (MD). O objetivo deste estudo é avaliar criticamente a concordância das medidas de desempenho de EVC em dois centros portugueses com diferentes plataformas de EVC. Métodos: Análise transversal de EVC consecutivas realizadas em 2 centros portugueses, com diferentes plataformas de EVC Mirocam® (IntroMedic, Seul, Coreia) e PillCam® (Medtronic, Yokneam, Israel), respetivamente. Um total de 10 medidas de desempenho (6 principais, 4 minor) foram avaliadas e comparadas entre os 2 centros. Resultados: Foram incluídas 493 EVC. O standard mínimo estabelecido pela ESGE foi alcançado em 3/6 MD principais (visualização completa, taxa de detecção de lesões e taxa de cápsula retida), e nenhum nas quatro MD minor. O cumprimento das MD diferiu significativamente entre os 2 centros: visualização completa do intestino delgado 95,9 e 90% (p = 0,01), taxa de deteção de lesões 50,6% e 63% (p = 0,005), adequada preparação do intestino delgado de acordo com a escala de Brotz 69,54 e 84,6% (p ≤ 0,001), doentes com alto risco de retenção da cápsula a quem foi oferecida cápsula de patência 4,2 e 73% (p ≤ 0,001), respectivamente. Introdução: Este estudo destaca e discute criticamente questões técnicas e organizacionais que devem ser consideradas na definição de limiares de MD mais realistas, com o objetivo de melhorar a qualidade da EVC.

Forecast models to predict the demand for endoscopic procedures in a tertiary unit: a prospective validation.

Over the past few decades, there has been an exponential increase in the utilization of endoscopic procedures. Accurately predicting the demand is crucial for effective capacity planning and resource allocation in the endoscopic unit. However, predictive models are not integrated into current endoscopy software. To overcome this limitation, our group used data on the demand in our tertiary unit from 2015 to 2021 (83 months) to develop forecast models using exponential smoothing techniques adjusted for trend and seasonality (derivation phase). These models were recently published at the Revista Española de Enfermedades Digestivas.

Hybrid Argon Plasma Coagulation for Barrett's Esophagus and for Colonic Mucosal Resection-A Systematic Review and Meta-Analysis.

Hybrid argon plasma coagulation (hAPC) is a novel technique that combines conventional argon plasma coagulation and waterjet submucosal expansion. The aims of this metanalysis were to evaluate the efficacy and safety of hAPC in the setting of Barret's esophagus (BE) ablation and as an adjunct to colonic endoscopic mucosal resection (EMR). Four electronic databases were searched, and the results were analyzed by two independent authors. Random-effects meta-analyses of the proportions of endoscopic and histologic remission (for BE), recurrence, and post-procedure adverse events were performed using R. Studies' reporting quality was also assessed. From the 979 identified records, 13 studies were included (10 regarding BE and three colonic EMR). The pooled percentages of endoscopic and histologic remission after hAPC for BE were 95% (95% confidence interval [CI] 91-99, I2 = 34) and 90% (95%CI 84-95, I2 = 46), respectively, while major adverse events and recurrence were registered in 2% (95%CI 0-5, I2 = 41) and 11% (95%CI 2-27, I2 = 11), respectively. Concerning hAPC-assisted EMR, the pooled percentages of major adverse events and recurrence were 5% (95%CI 2-10, I2 = 0) and 1% (95%CI 0-3, I2 = 40). Evidence suggests that the main advantages of hAPC are the increase in safety in the setting of BE ablation and the reduction of local recurrence after colonic EMR. Trials comparing hAPC with standard strategies are required to support its use for these indications.

Closure of a perforated endoscopic submucosal dissection eschar using three over-the-scope clips.

We report the use of three partially overlapping over-the-scope clips to close a perforated ESD eschar. This case illustrates the relevance of prompt acting to ensure ESD safety and reinforces the feasibility of endoscopic treatment for challenging iatrogenic perforations, reducing the need for urgent surgery and its related morbidity and mortality.

Small-bowel capsule endoscopy in patients with Meckel's diverticulum: clinical features, diagnostic workup, and findings. A European multicenter I-CARE study.

BACKGROUND AND AIMS: Meckel's diverticulum (MD) may remain silent or be associated with adverse events such as GI bleeding. The main aim of this study was to evaluate indicative small-bowel capsule endoscopy (SBCE) findings, and the secondary aim was to describe clinical presentation in patients with MD. METHODS: This retrospective European multicenter study included patients with MD undergoing SBCE from 2001 until July 2021. RESULTS: Sixty-nine patients with a confirmed MD were included. Median age was 32 years with a male-to-female ratio of approximately 3:1. GI bleeding or iron-deficiency anemia was present in nearly all patients. Mean hemoglobin was 7.63 ± 1.8 g/dL with a transfusion requirement of 52.2%. Typical capsule endoscopy (CE) findings were double lumen (n = 49 [71%]), visible entrance into the MD (n = 49 [71%]), mucosal webs (n = 30 [43.5%]), and bulges (n = 19 [27.5%]). Two or more of these findings were seen in 48 patients (69.6%). Ulcers were detected in 52.2% of patients (n = 36). In 63.8% of patients (n = 44), a combination of double lumen and visible entrance into the MD was evident, additionally revealing ulcers in 39.1% (n = 27). Mean percent SB (small bowel) transit time for the first indicative image of MD was 57% of the total SB transit time. CONCLUSIONS: Diagnosis of MD is rare and sometimes challenging, and a preoperative criterion standard does not exist. In SBCE, the most frequent findings were double-lumen sign and visible diverticular entrance, sometimes together with ulcers.

A full hemostatic repertoire in a complex cirrhotic patient.

A 55-year-old woman with cirrhosis was admitted for acute decompensation caused by portal vein thrombosis. Ten days later, the patient presented melena. Esophagogastroscopy revealed two gastric polyps, both with bleeding stigmata. One of the polyps was removed with a diathermic loop, after adrenalin injection, while in the other the "ligate and let go" technique was applied, after biopsy. A "metallic tulip-bundle" technique, combining through the scope and over-the-scope clips, was applied for hemostasis. This case underlines how the combination of various endoscopic techniques may be useful to manage upper gastrointestinal bleeding, especially in patients with important comorbidities.

Hemostasis of a bleeding inverted colonic diverticulum.

The authors report a case of a 62-year-old male presenting to the emergency department with hematochezia. Urgent colonoscopy revealed numerous diverticula in the sigmoid colon, two of them inverted. Oozing bleeding from a visible vessel was identified on the top of the most distal inverted diverticulum. An over-the-scope clip was released after suction into the transparent cap and successful hemostasis was achieved.