Randomized controlled trial of EndoRings assisted colonoscopy versus standard colonoscopy.

OBJECTIVES: The EndoRings device is a distal attachment consisting of two layers of circular flexible rings that evert mucosal folds. The aim of this study was to investigate whether EndoRing assisted colonoscopy (ER) improves polyp and adenoma detection compared to standard colonoscopy (SC). METHODS: Multicenter, parallel group, randomized controlled trial. RESULTS: Total of 556 patients randomized to ER (n = 275) or SC (n = 281). Colonoscopy completed in 532/556 (96%) cases. EndoRings removed in 74/275 (27%) patients. Total number of polyps in ER limb 582 vs. 515 in SC limb, P = 0.04. Total number of adenomas in ER limb 361 vs. 343 for SC limb, P = 0.49. A statistically significant difference in the mean number of polyps per patient in both the intention to treat (1.84 SC vs. 2.10 ER, P = 0.027) and per protocol (PP) (1.84 SC vs. 2.25 ER, P = 0.004). CONCLUSIONS: Our study shows promise for the EndoRings device to improve polyp detection.

Endoscopic characterization of small colonic polyps: baseline performance of experienced endoscopists is no different to that of medical students.

Background Studies examining the impact of training modules on characterization of diminutive colonic polyps (DCP) show varying results. Aim We aimed to assess the impact of a novel web-based training module on the accuracy of in vivo characterization of DCPs using different imaging modalities. Differences between groups with varying degrees of endoscopic experience were also assessed. Methods In total, 90 images of 30 DCPs viewed with high definition white light (HDWL), i-Scan, and indigo carmine chromoendoscopy were included in an online test module. Testing was undertaken before and after completing a novel web-based in vivo characterization training module. In total, 21 subjects (medical students (MS), gastroenterology trainees (GT), and gastroenterology consultants (GC)) undertook the tests and training module. Results No statistically significant difference in overall accuracy was found between the three groups either pre- (MS 59.1 %, GR 65.7 %, GC 62.4 %, P  = ns for all three comparisons) or post-training (MS 69.2 %, GR 71.1 %, GC 71.3 %, P  = ns for all three comparisons). Accuracy improved significantly for all three groups post-training ( P  < 0.001) as did interobserver agreement. No significant differences in accuracy between modalities were found pre-training (HDWL 64.8 %, i-Scan 60.0 %, chromoendoscopy 62.2 %, P  = ns). Post-training accuracy with HDWL and chromoendoscopy was better than with i-Scan (HDWL 72.9 % vs i-Scan 65.1 %, P  = 0.002; i-Scan 65.1 % vs chromoendoscopy 73.7 %, P  < 0.001). The proportion of high confidence predictions increased from 25.7 % to 41.5 %, with a high confidence prediction accuracy of 81.7 %. Conclusions Skills for in vivo characterization of DCPs are not acquired through endoscopic experience alone. A novel web-based training intervention results in modest improvements in accuracy with further improvements likely to require more prolonged training.

A randomized controlled trial of pre-procedure simethicone and N-acetylcysteine to improve mucosal visibility during gastroscopy - NICEVIS.

Background and study aims: Mucosal views can be impaired by residual bubbles and mucus during gastroscopy. This study aimed to determine whether a pre-gastroscopy drink containing simethicone and N-acetylcysteine improves mucosal visualisation. Patients and methods: We conducted a randomized controlled trial recruiting 126 subjects undergoing routine gastroscopy. Subjects were randomized 1:1:1 to receive: A-pre-procedure drink of water, simethicone and N-acetylcysteine (NAC); B-water alone; or C-no preparation. Study endoscopists were blinded to group allocation. Digital images were taken at 4 locations (lower esophagus/upper gastric body/antrum/fundus), and rated for mucosal visibility (MV) using a 4-point scale (1 = best, 4 = worst) by 4 separate experienced endoscopists. The primary outcome measure was mean mucosal visibility score (MVS). Secondary outcome measures were procedure duration and volume of fluid flush required to achieve adequate mucosal views. Results: Mean MVS for Group A was significantly better than for Group B (1.35 vs 2.11, P < 0.001) and Group C (1.35 vs 2.21, P < 0.001). Mean flush volume required to achieve adequate mucosal views was significantly lower in Group A than Group B (2.0 mL vs 31.5 mL, P = 0.001) and Group C (2.0 mL vs 39.2 mL P < 0.001). Procedure duration did not differ significantly between any of the 3 groups. MV scores at each of the 4 locations demonstrated significantly better mucosal visibility in Group A compared to Group B and Group C (P < 0.0025 for all comparisons). Conclusions: A pre-procedure drink containing simethicone and NAC significantly improves mucosal visibility during gastroscopy and reduces the need for flushes during the procedure. Effectiveness in the lower esophagus demonstrates potential benefit in Barrett's oesophagus surveillance gastroscopy.

General medical training in gastroenterology: views from specialist trainees on the challenges of dual accreditation.

Higher specialist training in general internal medicine (GIM) and the medical specialties has been subject to many changes and increasing subspecialisation in recent years. The 'Shape of Training' review proposes 'broad-based specialty training', shortening of training by one year, and subspecialisation to be undertaken after the certificate of specialty training is obtained. All higher level gastroenterology trainees based in the UK were invited to complete an online survey between July and September 2012 to assess their experience of gastroenterology and GIM training. Overall, 72.7% of trainees expressed satisfaction with their training in gastroenterology but significantly fewer (43.5%) expressed satisfaction with their training in GIM. Satisfaction with gastroenterology training thus is good, but satisfaction with GIM training is lower and levels of dissatisfaction have increased significantly since 2008. Up to 50% of trainees are not achieving the minimum recommended number of colonoscopy procedures for their stage of training. Experience in GIM is seen as service orientated, with a lack of training opportunities. There is a worrying difficulty in gaining the minimum required experience in endoscopy. If the length of specialist training is shortened and generalised, training in key core specialist skills such as endoscopy may be compromised further.

Endoscopic resection of sporadic duodenal adenomas: comparison of endoscopic mucosal resection (EMR) with hybrid endoscopic submucosal dissection (ESD) techniques and the risks of late delayed bleeding.

BACKGROUND: Endoscopic resection (ER) of sporadic duodenal adenomas (SDAs) is an alternative treatment strategy to surgical excision but carries substantial risks of bleeding. Endoscopic submucosal dissection (ESD) of SDAs has a high rate of perforation. This study aimed to examine the outcome for ER of SDAs in two large UK centers, both using a novel hybrid endoscopic mucosal resection (EMR) with ESD. METHODS: Prospective endoscopy databases of ER cases were examined for the period January 2005 to December 2012. Records were analyzed for patient demographics, lesion size and morphology, staging investigations, procedural technique, outcomes, histology, complications, and follow-up assessments. RESULTS: The study included 34 patients. The mean adenoma size was 25 mm. Of the 34 cases, 21 (62 %) were managed by the traditional snare EMR technique, 12 (35 %) by the hybrid EMR-ESD technique, and 1 by full en bloc ESD. Successful resection was achieved in 33 (97 %) of the 34 cases. En bloc resection and recurrence rates did not differ significantly between the cases treated by EMR and those treated by hybrid EMR-ESD. Three episodes of significant delayed bleeding occurred 1-18 days after the procedure. No perforations or deaths occurred. The risk of delayed bleeding was higher for the lesions 30 mm in diameter or larger than for the lesions smaller than 30 mm (33% vs. 0 %; p = 0.003). The risk of delayed bleeding was not related to the ER technique used (EMR, 9.5 %; ESD/hybrid, 7.7 %; p = 0.855). CONCLUSIONS: Endoscopic resection is an effective treatment for SDAs and can avoid the need for open surgery. This is the first series to report the use of a hybrid EMR-ESD technique for the treatment of SDAs in a Western setting. However, this technique did not confer any major outcome benefits over EMR. The risk of delayed bleeding is substantial, and bleeding may occur up to 18 days after the procedure. The risk of delayed bleeding was increased with lesions larger than 30 mm but was not influenced by the endoscopic technique.

High-definition endoscopy with i-Scan for evaluation of small colon polyps: the HiSCOPE study.

BACKGROUND: Traditional white-light endoscopy cannot reliably distinguish between small (<10 mm) adenomatous and hyperplastic colon polyps. High-definition white-light (HDWL) endoscopy and i-Scan may improve in vivo characterization of small colon polyps. OBJECTIVE: To compare HDWL endoscopy and HDWL plus i-Scan for the assessment of small colon polyps and to measure performance against the American Society for Gastrointestinal Endoscopy (ASGE) thresholds for assessment of diminutive colon polyps. DESIGN: Prospective cohort study. SETTING: Single academic hospital. PATIENTS: Patients undergoing bowel cancer screening colonoscopy. INTERVENTION: In vivo assessment of all polyps <10 mm by using HDWL and i-Scan image enhancement. MAIN OUTCOME MEASUREMENTS: The primary outcome measure was overall diagnostic accuracy of in vivo assessment of colon polyps <10 mm. Secondary outcome measures were sensitivity and specificity for adenomatous histology, negative predictive value for adenomatous histology of diminutive rectosigmoid polyps, and accuracy of prediction of polyp surveillance intervals. RESULTS: A total of 209 polyps in 84 patients were included. There were no significant differences between HDWL endoscopy and i-Scan in characterization of polyps <10 mm (accuracy 93.3% vs 94.7%; P = 1.00; sensitivity 95.5% vs 97.0%; P = .50; specificity 89.3% vs 90.7%; P = 1.00). The negative predictive value for adenomatous histology of diminutive rectosigmoid polyps was 100% with both HDWL endoscopy and i-Scan. U.K. and U.S. polyp surveillance intervals were predicted with 95.2% accuracy with HDWL endoscopy and 97.2% accuracy with i-Scan. LIMITATIONS: Single-center study. CONCLUSION: HDWL endoscopy may be as accurate as HDWL with i-Scan image enhancement for the in vivo characterization of small colon polyps. Both modalities fulfil the ASGE performance thresholds for the assessment of diminutive colon polyps. ( CLINICAL TRIAL REGISTRATION NUMBER: NCT01761279.).

Risk stratification system for evaluation of complex polyps can predict outcomes of endoscopic mucosal resection.

BACKGROUND: Apart from size, little is known about what makes a colonic polyp difficult to endoscopically remove. OBJECTIVE: The aim of this study was to evaluate polyp complexity by using a novel classification system and to assess how this affects success at endoscopic resection. DESIGN: This prospective cohort study was conducted at a tertiary referral center in the United Kingdom. INTERVENTIONS: Data were collected on patients referred for endoscopic resection of polyps >2 cm in size. Lesions were classified on the basis of size, morphology, site, and ease of access with the use of a novel scoring system (size/morphology/site/access). Endoscopic resection was performed to resect the lesions. Patients were followed up endoscopically to assess clinical outcomes. MAIN OUTCOME MEASURES: The primary outcomes measured were the endoscopic cure and complication rate by size/morphology/site/access grade and the cost savings of endoscopic resection over surgery. RESULTS: Endoscopic resection was performed on 220 patients (135 male) with 220 polyps, mean size of 43 mm (range, 20 mm-150 mm). Thirty-seven percent were classified as size/morphology/site/access 2 or 3; 63% were classified as the most challenging size/morphology/site/access level 4. Complete endoscopic clearance was achieved in 90% of cases with the first endoscopic resection attempt, improving to 96% with further endoscopic resection attempts. There were complications in 18 of 220 (8.1%) of cases. Complications were independent of lesion size and location but were affected by size/morphology/site/access grade (p = 0.018). Probability of clearance at first endoscopic resection attempt was affected by lesion complexity. Size/morphology/site/access 2 and 3 = 97.5 vs SMSA 4 = 87.5% (p = 0.009). Probability of cancer was not affected by size/morphology/site/access grade. For the whole cohort, endoscopic resection represented a cost saving of £726,288 ($1,123,858.05) over that of surgery. LIMITATIONS: The main limitation of this study is that it is a single-center, single-endoscopist series. CONCLUSIONS: The size/morphology/site/access scoring system is easy to use and provides valuable information on the lesion complexity and success and complication rates of endoscopic resection. This can be used for service planning, training endoscopists, and providing prognostic information for patients.

Managing difficult polyps: techniques and pitfalls.

There is no standardized definition of difficult polyps. However, polyps become difficult and challenging to remove endoscopically when they are large in size, flat in nature, situated in a high-risk location and when access to them is very awkward. Recently, an SMSA (Size, Morphology, Site, Access) classification has been proposed that helps to qualify the degree of difficulty by scoring on the above parameters. This article reviews the features that make polyps difficult to remove and provides some practical tips in managing these difficult polyps. We believe that 'difficult polyp' is a relative term and each endoscopist should define their own level of difficulty and what they would be able to handle safely. However, in expert trained hands, most difficult polyps can be safely removed by an endoscopic approach.

Endoscopic management of nonampullary duodenal polyps.

Duodenal polyps are a rare finding in patients presenting for gastroscopy, being found in 0.3-4.6% of cases. The majority of patients are asymptomatic. The most common lesions necessitating removal are duodenal adenomas which should be differentiated from other mucosal lesions such as ectopic gastric mucosa, and submucosal lesions such as carcinoids and gastrointestinal stromal tumours (GISTs). Adenomas can occur sporadically or as part of a polyposis syndrome. Both groups carry malignant potential but this is higher in patients with a polyposis syndrome. The majority of sporadic duodenal adenomas are flat or sessile and occur in the second part of the duodenum. Historically duodenal adenomas have been managed by radical surgery, which carried significant mortality and morbidity, or more conservative local surgical excision which resulted in high local recurrence rates. There is growing evidence for the use of endoscopic mucosal resection (EMR) techniques for treatment of sporadic nonampullary duodenal adenomas, with good outcomes and low complication rates. Endoscopic submucosal dissection (ESD) carries greater risk of complications and should be reserved for experts in this technique. Patients with sporadic duodenal adenomas carry an increased risk of colonic neoplasia and should be offered colonoscopy. The impact of endoscopic resection on the course of polyposis syndromes such as familial adenomatous polyposis (FAP) needs further study.