Accuracy and interrater reliability for the diagnosis of Barrett's neoplasia among users of a novel, portable high-resolution microendoscope.

The high-resolution microendoscope (HRME) is a novel imaging modality that may be useful in the surveillance of Barrett's esophagus in low-resource or community-based settings. In order to assess accuracy and interrater reliability of microendoscopists in identifying Barrett's-associated neoplasia using HRME images, we recruited 20 gastroenterologists with no microendoscopic experience and three expert microendoscopists in a large academic hospital in New York City to interpret HRME images. They prospectively reviewed 40 HRME images from 28 consecutive patients undergoing surveillance for metaplasia and low-grade dysplasia and/or evaluation for high-grade dysplasia or cancer. Images were reviewed in a blinded fashion, after a 4-minute training with 11 representative images. All imaged sites were biopsied and interpreted by an expert pathologist. Sensitivity of all endoscopists for identification of high-grade dysplasia or cancer was 0.90 (95% confidence interval [CI]: 0.88-0.92) and specificity was 0.82 (95% CI: 0.79-0.85). Positive and negative predictive values were 0.72 (95% CI: 0.68-0.77) and 0.94 (95% CI: 0.92-0.96), respectively. No significant differences in accuracy were observed between experts and novices (0.90 vs. 0.84). The kappa statistic for all raters was 0.56 (95% CI: 0.54-0.58), and the difference between groups was not significant (0.64 vs. 0.55). These data suggest that gastroenterologists can diagnose Barrett's-related neoplasia on HRME images with high sensitivity and specificity, without the aid of prior microendoscopy experience.

Small-bowel endoscopy.

This review of the literature on endoscopy of the small bowel focuses on published reports, and does not include abstracts. The literature was reviewed for the period September 2001 to September 2002. MEDLINE was searched under the topics of "small-bowel endoscopy", "small bowel", "enteroscopy", "obscure bleeding", and "wireless endoscopy", and a hand search was also carried out of the major gastroenterology journals, along with a review of the tables of contents of all journals that could be identified as being related to gastroenterology or gastrointestinal endoscopy. Sonde small-bowel enteroscopy is no longer an option, and has been rightfully retired as an investigation tool for the small bowel. There is still a place for further evaluation of push enteroscopy, as evidenced by the 11 papers published since the last review of small-bowel endoscopy in 2002. In the field of intraoperative enteroscopy, only one series and a handful of case reports have appeared. By contrast, wireless capsule endoscopy of the small bowel has captured the imagination of gastroenterologists throughout the world. Up to 2003, there have not been many published papers concerning this new diagnostic modality, since patients with obscure gastrointestinal bleeding or suspected small-bowel disease are relatively scarce. Large numbers of abstracts concerning capsule endoscopy have been submitted for presentation at major gastroenterology and gastrointestinal endoscopy meetings over the past 2 years, and the enthusiasm for this new technique of small-bowel imaging has increased with reports of its successful application.

Polyp retrieval after colonoscopic polypectomy: use of the Roth Retrieval Net.

BACKGROUND: All colon polyps removed during colonoscopy should be recovered and submitted for histopathologic analysis. Published information is scant regarding techniques and devices for retrieval of polyps after polypectomy. The Roth Retrieval Net is a novel device that has been used to retrieve foreign bodies from the GI tract, but its use as a polyp retrieval device has not previously been described. METHODS: A chart review was conducted over a 7-month period by one gastroenterologist in an office setting of all patients who had polyps retrieved after piecemeal polypectomy by using the Roth Retrieval Net. RESULTS: All resected polyps were completely retrieved in a time-efficient manner. Histopathologic evaluation was not compromised by the use of this device. CONCLUSIONS: The Roth Retrieval Net is well suited for retrieval of multiple polyp fragments after colonoscopic polypectomy.

The evolution of gastrointestinal endoscopy at the Mount Sinai Hospital.

Gastrointestinal endoscopy came to The Mount Sinai Hospital in the 1950s, along with the Wolf-Schindler gastroscope. In 1961, it was supplemented by the Eder-Hufford semi-flexible esophagoscope and later by the Olympus gastrocamera and then the Hirschowitz fiberoptic instruments from ACMI and Olympus. A formal training program was started by Jerome Waye in 1966 for flexible gastroscopy and esophagoscopy. In 1969, endoscopic retrograde cholangiopancreatography (ERCP) was introduced. Colonoscopy was at first performed under x-ray control, and subsequently replaced by the nonfluoroscopic method of colonoscopic topography, which was developed by Dr. Waye. A full-time nurse who was in charge of the endoscopy unit founded the Society for Gastrointestinal Nurses and Assistants while working at The Mount Sinai Hospital.

Small-intestinal endoscopy.

A small imaging capsule without cables, wires, or external connections has been developed for exploration of the small bowel. This swallowable device is propelled by peristalsis through the intestinal tract, and transmits data to a nearby receiver that captures video images on a regular basis. This technology will soon be available throughout the world, and it promises to revolutionize deep endoscopy of the small bowel. Sonde enteroscopy will be laid to rest forever. There continues to be considerable interest in the use of push enteroscopy in the investigation of obscure gastrointestinal bleeding. Physicians are beginning to rely more on intraoperative enteroscopy, because of its high degree of accuracy and its ability to provide visualization of the entire small bowel in selected patients in whom the bleeding source cannot be diagnosed, but who require blood transfusions.

Endoscopic mucosal resection of colon polyps.

The term submucosal injection polypectomy (SIP) more accurately describes the technique used for removal of flat colonic polyps and is preferred, in the colon, to endoscopic mucosal resection (a procedure that usually uses a special suction-activated device). Using SIP, most polyps can be removed safely from any part of the colon. The methodology is described in detail and is within the capability of most colonoscopists.

Fifty landmark discoveries in gastroenterology during the past 50 years. A brief history of modern gastroenterology at the millennium: Part II. Gastrointestinal motility, nutrition, and diseases of the lower gastrointestinal tract, liver, and pancreas.

During the last half century, many outstanding discoveries have revolutionized the clinical practice and science of gastroenterology. Although the scientific results are widely disseminated, the discoverers have received inadequate recognition and the history of their discoveries is largely unstudied and unknown. At the millennium, a committee selected 50 landmark discoveries in gastroenterology during the past 50 years. A brief history of each landmark discovery is presented. Part I was presented in the previous issue of Gastroenterology Clinics of North America. Part II presents landmark discoveries in gastrointerintal (GI) motility, clinical trials, nutrition, and diseases of the lower GI tract, liver, biliary tree, and pancreas.

A comparison of colonoscopy and double-contrast barium enema for surveillance after polypectomy. National Polyp Study Work Group.

BACKGROUND: After patients have undergone colonoscopic polypectomy, it is uncertain whether colonoscopic examination or a barium enema is the better method of surveillance. METHODS: As part of the National Polyp Study, we offered colonoscopic examination and double-contrast barium enema for surveillance to patients with newly diagnosed adenomatous polyps. Although barium enema was performed first, the endoscopist did not know the results. RESULTS: A total of 973 patients underwent one or more colonoscopic examinations for surveillance. In the case of 580 of these patients, we performed 862 paired colonoscopic examinations and barium-enema examinations that met the requirements of the protocol. The findings on barium enema were positive in 222 (26 percent) of the paired examinations, including 139 of the 392 colonoscopic examinations in which one or more polyps were detected (rate of detection, 35 percent; 95 percent confidence interval, 31 to 40 percent). The proportion of examinations in which adenomatous polyps were detected by barium enema colonoscopy was significantly related to the size of the adenomas (P=0.009); the rate was 32 percent for colonoscopic examinations in which the largest adenomas detected were 0.5 cm or less, 53 percent for those in which the largest adenomas detected were 0.6 to 1.0 cm, and 48 percent for those in which the largest adenomas detected exceeded 1.0 cm. Among the 139 paired examinations with positive results on barium enema and negative results on colonoscopic examination in the same location, 19 additional polyps, 12 of which were adenomas, were detected on colonoscopic reexamination. CONCLUSIONS: In patients who have undergone colonoscopic polypectomy, colonoscopic examination is a more effective method of surveillance than double-contrast barium enema.

Approach to colon polyps in the elderly.

Colorectal cancer is a common but potentially preventable disease. Nearly all colorectal cancers are thought to arise from adenomatous polyps. The conclusions from the National Polyp Study strongly support the concept that the removal of polyps may prevent the future development of colorectal cancer. With the growing acceptance of screening for colorectal cancer, many elderly patients with adenomatous polyps will be discovered. Because increasing age is a powerful determinant of a higher prevalence of colonic neoplasia in asymptomatic individuals, physicians will need to be prepared to make informed decisions regarding the treatment of elderly patients with colonic polyps. The literature is reviewed and guidelines are formed regarding the optimal surveillance interval for patients with colonic polyps. The age at which surveillance and screening for colorectal neoplasia should stop is also reviewed. Conclusions are based on the currently available data.