The Effect of Oral Simethicone in a Bowel Preparation in a Colorectal Cancer Screening Colonoscopy Setting: A Randomized Controlled Trial.

Introduction: Current guidelines suggest adding oral simethicone to bowel preparation for colonoscopy. However, its effect on key quality indicators for screening colonoscopy remains unclear. The primary aim was to assess the rate of adequate bowel preparation in split-dose high-volume polyethylene glycol (PEG), with or without simethicone. Methods: This is an endoscopist-blinded, randomized controlled trial, including patients scheduled for colonoscopy after a positive faecal immunochemical test. Patients were randomly assigned to 4 L of PEG split dose (PEG) or 4 L of PEG split dose plus 500 mg oral simethicone (PEG + simethicone). The Boston Bowel Preparation Scale (BBPS) score, the preparation quality regarding bubbles using the Colon Endoscopic Bubble Scale (CEBuS), ADR, CIR, and the intraprocedural use of simethicone were recorded. Results: We included 191 and 197 patients in the PEG + simethicone group and the PEG group, respectively. When comparing the PEG + simethicone group versus the PEG group, no significant differences in adequate bowel preparation rates (97% vs. 93%; p = 0.11) were found. However, the bubble scale score was significantly lower in the PEG + simethicone group (0 [0] versus 2 [5], p < 0.01), as well as intraprocedural use of simethicone (7% vs. 37%; p < 0.01). ADR (62% vs. 61%; p = 0.86) and CIR (98% vs. 96%, p = 0.14) did not differ between both groups. Conclusion: Adding oral simethicone to a split-bowel preparation resulted in a lower incidence of bubbles and a lower intraprocedural use of simethicone but no further improvement on the preparation quality or ADR.

Introdução: As normas de orientação atuais sugerem a adição de simeticone oral à preparação intestinal para colonoscopia. Contudo, o seu efeito nos indicadores de qualidade no âmbito da colonoscopia de rastreio não está comprovado. O objetivo principal foi avaliar a taxa de preparação adequada usando polietilenoglicol (PEG) em dose dividida com e sem simeticone oral. Métodos: Estudo randomizado controlado, cego para o endoscopista, incluindo doentes admitidos para colonoscopia após teste fecal imunoquímico positivo. Os doentes foram aleatoriamente alocados para 4 litros de PEG em dose dividida (PEG) ou 4 litros de PEG em dose divida + simeticone oral (PEG + simeticone). Foram avaliados: Boston Bowel Preparation Scale (BBPS), qualidade da preparação relativa às bolhas através da Colon Endoscopic Bubble Scale (CEBuS) scale, ADR, CIR e uso de simeticone durante o procedimento. Resultados: Foram incluídos 191 e 197 doentes nos grupos PEG + simeticone e PEG, respetivamente. Comparando os grupos PEG + simeticone versus PEG, não se registaram diferenças de significado estatístico relativamente à taxa de preparação intestinal adequada (97% vs. 93%; p = 0,01) mas o score da escala de bolhas foi significativamente inferior no grupo PEG + simeticone [0 (0) versus 2 (5), p < 0.01], assim como o uso de simeticone durante o procedimento (7% vs. 37%; p < 0,01). A ADR (62% vs. 61%; p = 0,86) e a CIR (98% vs. 96%, p = 0,14) não diferiram significativamente entre os dois grupos, respetivamente. Discussão/Conclusão: Adicionar simeticone oral à preparação intestinal em dose dividida permitiu menor incidência de bolhas e menor utilização de simeticone durante o procedimento, mas não se associa a melhor preparação intestinal ou melhor ADR.

Cap-Assisted Endoscopic Mucosal Resection for Rectal Neuroendocrine Tumors: An Effective Option.

Introduction: The incidence of rectal neuroendocrine tumors (r-NETs) is increasing, and most small r-NETs can be treated endoscopically. The optimal endoscopic approach is still debatable. Conventional endoscopic mucosal resection (EMR) leads to frequent incomplete resection. Endoscopic submucosal dissection (ESD) allows higher complete resection rates but is also associated with higher complication rates. According to some studies, cap-assisted EMR (EMR-C) is an effective and safe alternative for endoscopic resection of r-NETs. Aims: This study aimed to evaluate the efficacy and safety of EMR-C for r-NETs ≤10 mm without muscularis propria invasion or lymphovascular infiltration. Methods: Single-center prospective study including consecutive patients with r-NETs ≤10 mm without muscularis propria invasion or lymphovascular invasion confirmed by endoscopic ultrasound (EUS), submitted to EMR-C between January 2017 and September 2021. Demographic, endoscopic, histopathologic, and follow-up data were retrieved from medical records. Results: A total of 13 patients (male: 54%; n = 7) with a median age of 64 (interquartile range: 54-76) years were included. Most lesions were located at the lower rectum (69.2%, n = 9), and median lesion size was 6 (interquartile range: 4.5-7.5) mm. On EUS evaluation, 69.2% (n = 9) of tumors were limited to muscularis mucosa. EUS accuracy for the depth of invasion was 84.6%. We found a strong correlation between size measurements by histology and EUS (r = 0.83, p < 0.01). Overall, 15.4% (n = 2) were recurrent r-NETs and had been pretreated by conventional EMR. Resection was histologically complete in 92% (n = 12) of cases. Histologic analysis revealed grade 1 tumor in 76.9% (n = 10) of cases. Ki-67 index was inferior to 3% in 84.6% (n = 11) of cases. The median procedure time was 5 (interquartile range: 4-8) min. Only 1 case of intraprocedural bleeding was reported and was successfully controlled endoscopically. Follow-up was available in 92% (n = 12) of cases with a median follow-up of 6 (interquartile range: 12-24) months with no evidence of residual or recurrent lesion on endoscopic or EUS evaluation. Conclusion: EMR-C is fast, safe, and effective for resection of small r-NETs without high-risk features. EUS accurately assesses risk factors. Prospective comparative trials are needed to define the best endoscopic approach.

Introdução: Os tumores neuroendócrinos do reto (r-NETs) apresentam incidência crescente. A maioria dos tumores de pequenas dimensões pode ser excisada endoscopicamente, no entanto, a abordagem ótima é controversa. A mucosectomia convencional associa-se, frequentemente, a resseção endoscópica incompleta. A disseção endoscópica submucosa (ESD) permite elevadas taxas de resseção completa, mas é tecnicamente complexa e associa-se a maior número de complicações. Alguns estudos sugerem a mucosectomia assistida por cap (EMR-C) como uma alternativa eficaz e segura. Objetivo: Este estudo pretendeu avaliar a eficácia e segurança da mucosectomia com cap na resseção de r-NETs com dimensões ≤10 mm, sem invasão da muscularis própria nem infiltração linfovascular. Material e Métodos: Estudo prospetivo unicêntrico incluindo consecutivamente r-NETs com ≤10 mm, sem invasão da muscularis própria ou linfovascular confirmada em ultrassonografia endoscópica (EUS), submetidos a mucosectomia assistida cap entre janeiro de 2017 e setembro de 2021. Colheita de dados demográficos, clínicos e histopatológicos através de registos médicos eletrónicos. Resultados: Incluídos 13 doentes (género masculino: 54%; n = 7) com idade mediana de 64 (intervalo interquartil [IIQ]: 54­76) anos. A maioria das lesões localizava-se no reto inferior (69.2%; n = 9) e apresentava tamanho mediano de 6 (IIQ: 4.5­7.5) mm. Na avaliação por EUS, 69.2% (n = 9) encontravam-se limitados à muscularis mucosa. A acuidade da EUS na avaliação do envolvimento das camadas da parede retal foi de 84.6% e o tamanho avaliado por EUS correlacionou-se fortemente com o medido na histologia (r = 0.83, p < 0.01). Dois casos (15.4%) corresponderam a recorrências de mucosectomias convencionais prévias. A resseção foi macroscópica e histologicamente completa em 92% (n = 12) dos casos. A análise histológica revelou 76.9% (n = 10) tumores de grau 1. O índice Ki-67 foi inferior a 3% em 84.6% (n = 11) dos casos. O tempo mediano de procedimento foi 5 (IIQ: 4­8) minutos. Verificou-se apenas um caso de hemorragia intraprocedimento resolvida endoscopicamente. O seguimento de 92% dos casos (n = 12) com mediana de 6 (IIQ:12­24) meses não revelou lesão residual ou recorrência em avaliações endoscópica e ultrassonográfica. Discussão/Conclusão: A EMR-C é uma técnica endoscópica segura, rápida e efetiva para a resseção de r-TNEs pequenos sem fatores de alto risco. A EUS apresenta elevada acuidade na avaliação dos fatores de risco. Estudos comparativos prospetivos são necessários para estabelecimento da abordagem endoscópica mais profícua.

Can white-light endoscopy or narrow-band imaging avoid biopsy of colorectal endoscopic mucosal resection scars? A multicenter randomized single-blind crossover trial.

BACKGROUND : Current guidelines suggest that routine biopsy of post-endoscopic mucosal resection (EMR) scars can be abandoned, provided that a standardized imaging protocol with virtual chromoendoscopy is used. However, few studies have examined the accuracy of advanced endoscopic imaging, such as narrow-band imaging (NBI) vs. white-light endoscopy (WLE) for prediction of histological recurrence. We aimed to assess whether NBI accuracy is superior to that of WLE and whether one or both techniques can replace biopsies. METHODS : The study was a multicenter, randomized, pathologist-blind, crossover trial, with consecutive patients undergoing first colonoscopy after EMR of lesions ≥ 20 mm. Computer-generated randomization and opaque envelope concealed allocation. Patients were randomly assigned to scar examination with NBI followed by WLE (NBI + WLE), or WLE followed by NBI (WLE + NBI). Histology was the reference method, with biopsies being performed for all tissues. RESULTS : The study included 203 scars (103 in the NBI + WLE group, 100 in the WLE + NBI group). Recurrence was confirmed histologically in 29.6 % of the scars. The diagnostic accuracy of NBI was not statistically different from that of WLE (95 % [95 %CI 92 %-98 %] vs. 94 % [95 %CI 90 %-97 %]; P = 0.48). The negative predictive values (NPVs) were 96 % (95 %CI 93 %-99 %) for NBI and 93 % (95 %CI 89 %-97 %) for WLE (P = 0.06). CONCLUSIONS : The accuracy of NBI for the diagnosis of recurrence was not superior to that of WLE. Endoscopic assessment of EMR scars with WLE and NBI achieved an NPV that would allow routine biopsy to be avoided in cases of negative optical diagnosis.

Gastric Hyperplastic Polyps: A Benign Entity? Analysis of Recurrence and Neoplastic Transformation in a Cohort Study.

INTRODUCTION: Hyperplastic polyps represent 30-93% of all gastric epithelial polyps. They are generally detected as innocuous incidental findings; however, they have a risk of neoplastic transformation and recurrence. Frequency and risk factors for neoplastic transformation and recurrence are not well established and are fields of ongoing interest. This study aims to evaluate the frequency of and identify the risk factors for recurrence and neoplastic change of gastric hyperplastic polyps (GHP). METHODS: A single-centre retrospective cohort study including consecutive patients who underwent endoscopic resection of GHP from January 2009 to June 2020. Demographic, endoscopic, and histopathologic data was retrieved from the electronic medical records. RESULTS: A total of 195 patients were included (56% women; median age 67 [35-87] years). The median size of GHP was 10 (3-50) mm, 62% (n = 120) were sessile, 61% (n = 119) were located in the antrum, and 36% (n = 71) had synchronous lesions. Recurrence rate after endoscopic resection was 23% (n = 26). In multivariate analysis, antrum location was the only risk factor for recurrence (odds ratio [OR] 3.0; 95% confidence interval [CI] 1.1-8.1). Overall, 5.1% (n = 10) GHP showed neoplastic transformation, with low-grade dysplasia in 5, high-grade dysplasia in 4, and adenocarcinoma in 1. In multivariate analysis, a size >25 mm (OR 84; 95% CI 7.4-954) and the presence of intestinal metaplasia (OR 7.6; 95% CI 1.0-55) and dysplasia (OR 86; 95% CI 10-741) in adjacent mucosa were associated with an increased risk of neoplastic transformation. Recurrence was not associated with neoplastic transformation (OR 1.1; 95% CI 0.2-5.9). DISCUSSION: Our results confirmed the risk of recurrence and neoplastic transformation of GHP. Antrum location was a predictor of recurrence. The risk of neoplastic change was increased in large lesions and with intestinal metaplasia and dysplasia in adjacent mucosa. More frequent endoscopic surveillance may be required in these subgroups of GHP.

INTRODUÇÃO E OBJETIVOS: Os pólipos hiperplásicos constituem 30­93% das lesões gástricas epiteliais benignas. Apresentam-se frequentemente como achados endoscópicos incidentais inocuos, no entanto, apresentam risco de recorrência e transformação neoplásica. A frequência e fatores associados à recorrência e transformação neoplásica não estão bem estabelecidos e são áreas de interesse crescente. Este estudo pretende avaliar a frequência e identificar fatores associados à recorrência e transformado maligna dos pólipos gástricos hiperplásicos (PGH). MÉTODOS: Estudo de coorte retrospectivo unicèntrico incluindo consecutivamente doentes com PGH submetidos a ressedo endoscópica entre janeiro de 2009 e junho de 2020. Efetuada análise das características demográficas, endoscópicas e anatomopatológicas através dos registos clínicos eletrónicos. SUMARIOS DOS RESULTADOS: Incluídos 195 doentes género feminino: 56%, idade mediana: 67 (35­87) anos. Os pólipos apresentavam tamanho mediano de 10 (3­50) mm, 61.5% (n = 120) eram sésseis, 61% (n = 119) apresentavam localização antral e 36% (n = 71) tinham lesões síncronas. A frequência de recorrência foi 23% (n = 26). Na análise multivariada, apenas a localização no antro se associou significativamente a recorrência odds ratio (OR): 3.0; intervalo de confiança (IC) 95%: 1.1­8.1). Em 5.1% (n = 10) dos casos verificou-se transformação neoplásica, correspondendo a 5 casos de displasia de baixo grau, 4 casos de displasia de alto grau e 1 caso de carcinoma. Na análise multivariada, dimensão superior a 25 mm (OR: 84; IC95%: 7.4­954), presença de metaplasia (OR: 7.6; IC95%: 1.0­55) e displasia (OR: 86; IC95%: 10­741) na mucosa adjacente associaram-se a transformação neoplásica. A recorrência não se associou a transformação neoplásica (OR: 1.1; IC95%: 0.2­5.9). DISCUSSÃO/CONCLUSÃO: Estes resultados corroboraram os riscos de recorrência e transformado neoplásica associados aos PGH. A localização antral foi preditor de recorrência. O risco de transformado neoplásica foi superior em lesões maiores e coexistência de metaplasia e displasia na mucosa adjacente. Poderá justificar-se uma estratégia de vigilancia mais frequente nestes subgrupos.

A 3-day low-fibre diet does not improve colonoscopy preparation results compared to a 1-day diet: A randomized, single-blind, controlled trial.

Background: Although a 1-day low-fibre diet before colonoscopy is currently recommended, some endoscopists prescribe a 3-day diet. Objective: The objective of this study was to compare the influence of a 3-day versus a 1-day low-fibre diet on bowel preparation quality, patient tolerability and adherence. Methods: Outpatients scheduled for total colonoscopy were randomized in two groups, 3-day versus 1-day low-fibre diet, performing a 4-litre polyethylene glycol split-dose. The primary outcome was a reduction of inappropriate preparations in the 3-day low-fibre diet arm from 15% to 5% (bowel preparation was assessed by the Boston Bowel Preparation Scale). Secondary outcomes were adherence to, difficulty to perform, difficulty to obtain and willingness to repeat the diet. Intention-to-treat (ITT) and per-protocol (PP) analyses were conducted for the primary outcome. Results: A total of 412 patients were randomized (206 per group). Bowel preparation quality was similar between groups. On ITT analysis (n = 412), adequate bowel preparation was 91.7% (3-day diet) versus 94.7% (1-day diet), p = 0.24 and on PP analysis (n = 400) 93.5% versus 96.5%, respectively, p = 0.16. Difficulty to perform the diet was significantly higher on the 3-day diet, p = 0.04. No differences were found on difficulty to obtain the diet, willingness to repeat the diet, adverse events and intra-colonoscopy findings. Conclusion: A 3-day low-fibre diet does not bring benefit to the bowel preparation quality and is harder to perform than a 1-day diet.

Gastric neuroendocrine neoplasm with late liver metastasis.

Gastric neuroendocrine neoplasms (GNENs) are classified into three types according to their aetiology. We present a clinical case of a female patient of 66 years and a well-differentiated (grade 2), type 3 GNEN with late liver metastasis (LM). The patient underwent surgical excision of a gastric lesion at 50 years of age, without any type of follow-up. Sixteen years later, she was found to have a neuroendocrine tumour (NET) metastatic to the liver. The histological review of the gastric lesion previously removed confirmed that it was a NET measuring 8 mm, pT1NxMx (Ki67 = 4%). 68Ga-DOTANOC PET/CT reported two LM and a possible pancreatic tumour/gastric adenopathy. Biopsies of the lesion were repeatedly inconclusive. She had a high chromogranin A, normal gastrin levels and negative anti-parietal cell and intrinsic factor antibodies, which is suggestive of type 3 GNEN. She underwent total gastrectomy and liver segmentectomies (segment IV and VII) with proven metastasis in two perigastric lymph nodes and both with hepatic lesions (Ki67 = 5%), yet no evidence of local recurrence. A 68Ga-DOTANOC PET/CT was performed 3 months after surgery, showing no tumour lesions and normalisation of CgA. Two years after surgery, the patient had no evidence of disease. This case illustrates a rare situation, being a type 3, well-differentiated (grade 2) GNEN, with late LM. Despite this, it was possible to perform surgery with curative intent, which is crucial in these cases, as systemic therapies have limited efficacy. We emphasise the need for extended follow-up in these patients. LEARNING POINTS: GNENs have a very heterogeneous biological behaviour.Clinical distinction between the three types of GNEN is essential to plan the correct management strategy.LMs are rare and more common in type 3 and grade 3 GNEN.Adequate follow-up is crucial for detection of disease recurrence.Curative intent surgery is the optimal therapy for patients with limited and resectable LM, especially in well-differentiated tumours (grade 1 and 2).

Quality in Colonoscopy: Beyond the Adenoma Detection Rate Fever.

BACKGROUND: Colonoscopy quality is a hot topic in gastroenterological communities, with several actual guidelines focusing on this aspect. Although the adenoma detection rate (ADR) is the single most important indicator, several other metrics are described and need reporting. Electronic medical reports are essential for the audit of quality indicators; nevertheless, they have proved not to be faultless. AIM: The aim of this study was to analyse and audit quality indicators (apart from ADR) using only our internal electronic endoscopy records as a starting point for improvement. METHODS: An analysis of electronically recorded information of 8,851 total colonoscopies from a single tertiary centre from 2010 to 2015 was performed. RESULTS: The mean patient age was 63.4 ± 8.5 years; 45.5% of them were female, and in 14.6% sedation was used. Photographic documentation was done in 98.4% with 10.7 photographs on average, and 37.4% reports had <8 pictures per exam. Bowel preparation was rated as adequate in 67%, fair in 27% and inadequate in 4.9% of cases. The adjusted caecal intubation rate (CIR) was 92%, while negative predictors were inadequate preparation (OR 119, 95% CI 84-170), no sedation (OR 2.39, 95% CI 1.81-3.15), female gender (OR 1.61, 95% CI 1.38-1.88) and age ≥65 years (OR 1.56, 95% CI 1.34-1.82). In 28% of patients, a snare polypectomy was performed, correlating with adequate preparation (OR 5.75, 95% CI 3.90-8.48), male gender (OR 1.82, 95% CI 1.64-2.01) and age ≥65 years (OR 1.25, 95% CI 1.13-1.37; p < 0.01) as positive predictors. An annual evolution was observed with improvements in photographic documentation (10.7 vs. 12.9; p < 0.001), CIR (91 vs. 94%; p = 0.002) and "adequate" bowel preparation (p = 0.004). Conclusions: There is much more to report than the ADR to ensure quality in colonoscopy practice. Better registry systematization and integrated software should be goals to achieve in the short term.

INTRODUÇÃO: A qualidade em colonoscopia tem sido um tópico de importante discussão com várias orientações publicadas nesta área. Embora a taxa de deteção de adenomas (ADR) seja o indicador mais importante, vários outros indicadores estão descritos e precisam ser estudados/publicados. Os registos médicos eletrónicos são essenciais para a auditoria de indicadores de qualidade, mas provaram não ser infalíveis. OBJETIVO: Analisar e auditar os indicadores de qualidade, além do ADR, recorrendo apenas à base de dados de endoscopia do nosso centro, como ponto de partida para a melhoria. MÉTODOS: Análise do registo eletrónico de 8,851 colonoscopias totais realizadas em um único centro no período 2010­2015. RESULTADOS: A idade média dos pacientes foi de 63.4 ± 8.5 anos, 45.5% do sexo feminino. Em 14.6%, foi utilizada sedação. Documentação fotográfica em 98.4%, com média de 10.7 fotografias por exame e 37.4% com menos de 8 fotos por exame. A preparação intestinal foi avaliada como "adequada" em 67%, "razoável" em 27% e "inadequada" em 4.9%. A taxa de intubação cecal ajustada (CIR) foi de 92%, com preparação inadequada (OR 119, 95% CI 84­170), exame sem sedação (OR 2.39, 95% CI 1.81­3.15), sexo feminino (OR 1.61, 95% CI 1.38­1.88) e idade ≥65 (OR 1.56, 95% CI 1.34­1.82) como preditores negativos. Em 28%, foi realizada polipectomia, correlacionando-se com preparação "adequada" (OR 5.75, 95% CI 3.90­8.48), sexo masculino (OR 1.82, 95% CI 1.64­2.01) e idade ≥65 (OR 1.25, 95% CI 1.13­1.37; p < 0.01). Da evolução anual destacar melhorias na documentação fotográfica (10.7 vs. 12.9; p < 0.001), taxa de intubação cecal (91 vs. 94%; p = 0.002) e preparação intestinal "adequada" (p = 0.004). CONCLUSÕES: Há muito mais para reportar, além do ADR, de modo a garantir colonoscopias com qualidade. Uma maior sistematização no registo e softwares integrados devem ser objetivos a alcançar no curto prazo.

Impact of Personalised Patient Education on Bowel Preparation for Colonoscopy: Prospective Randomised Controlled Trial.

BACKGROUND: Adequate bowel preparation is one of the most important quality factors of colonoscopy. Our goal was to analyse the impact of personalised patient education on bowel cleansing preparation for colonoscopy. METHODS: We performed a single-blinded, single-centre, prospective randomised trial, where patients were either allocated to a control group, where they received some predefined oral and written information on bowel preparation from the gastroenterologist, or to an intervention group, where patients received additional personalised instructions for bowel preparation and diet from a nurse. The primary outcome was the quality of bowel preparation (Aronchick scale). RESULTS: A total of 229 patients were randomised; 113 to the control group and 116 to the intervention group. In intention-to-treat analysis, bowel preparation was adequate in 62% (95% CI 53-70) of colonoscopies in the intervention group and in 35% (95% CI 26-44) of colonoscopies in the control group (p < 0.001). The absolute risk reduction was 27%, the relative risk was 1.77, and the number needed to treat was 4. Subgroup analysis showed a significant impact of personalised education in patients under 65 years (67 vs. 35%; p < 0.001), in males (60 vs. 33%; p = 0.003), in those with higher educational levels (68 vs. 37%; p = 0.002), in those living in urban areas (68 vs. 40%; p = 0.004), and in those with previous colonoscopy (68 vs. 40%; p = 0.001). Risk factors for inadequate preparation were: male gender (OR = 2.1; 95% CI 1.1-4.1), diabetes mellitus (OR = 3.8; 95% CI 1.2-11.6), chronic constipation (OR = 3.7; 95% CI 1.7-8.2), absence of prior abdominal surgery (OR = 2.2; 95% CI 1.2-4.1), and being in the control group (OR = 2.5; 95% CI 1.4-4.4). CONCLUSIONS: Personalised patient education on bowel preparation for colonoscopy significantly improved the quality of bowel preparation.

INTRODUÇÃO: Uma adequada preparação intestinal é um dos fatores de qualidade mais importantes de uma colonoscopia. O objetivo foi analisar o impacto do ensino personalizado na qualidade da preparação intestinal. MATERIAL E MÉTODOS: Estudo prospetivo randomizado, cego para o endoscopista, num único centro hospitalar. Os doentes foram randomizados em 2 grupos: "controlo" - receberam informação pré-definida sobre a preparação intestinal pelo gastrenterologista assistente; "intervenção" - após a consulta com gastrenterologista receberam informações personalizadas em consulta de enfermagem, com explicação pormenorizada da preparação e dieta. O outcome primário foi a qualidade da preparação intestinal (escala de Aronchick). RESULTADOS: Randomizados 229 doentes, 113 no grupo "controlo" e 116 no "intervenção". As preparações foram consideradas "adequadas" em 62% (95% IC 53-70) das colonoscopias do grupo "intervenção" e em 35% (95% IC 26-44) do grupo "controlo" (p = 0.001). A redução de risco absoluto foi 27%, risco relativo 1.77 e número necessário para tratar de 4. A análise de subgrupos revelou um impacto mais significativo do ensino personalizado nos doentes até 65 anos (67 vs. 35%, p < 0.001), sexo masculino (60 vs. 33%, p = 0.003), maior grau de escolaridade (68 vs. 37%, p = 0.002), residentes em meio urbano (68 vs. 40%, p = 0.004) e com colonoscopias prévias (68 vs. 40%, p = 0.001). Foram identificados como fatores de risco para má preparação: género masculino (OR = 2.1; 95% IC 1.1-4.1), diabetes mellitus (OR = 3.8; 95% IC 1.2-11.6), obstipação (OR = 3.7; 95% IC 1.7-8.2), inexistência de cirurgia abdominal prévia (OR = 2.2; 95% IC 1.2-4.1) e ausência de ensino personalizado (OR = 2.5; 95% IC 1.4-4.4). CONCLUSÃO: O ensino personalizado da preparação intestinal para colonoscopia melhora significativamente a qualidade da preparação intestinal.

Premedication with simethicone and N-acetylcysteine in improving visibility during upper endoscopy: a double-blind randomized trial.

Background and study aim Upper endoscopy is the most common method for the diagnosis of upper gastrointestinal tract diseases. The aim of this study was to determine whether premedication with simethicone or N-acetylcysteine improves mucosal visualization during upper endoscopy. Patients and methods This was a randomized, double-blind, placebo-controlled study of 297 patients scheduled for upper endoscopy who were premedicated 15 - 30 minutes before the procedure with: 100 mL of water (placebo, group A); water plus 100 mg simethicone (group B); water plus 100 mg simethicone plus 600 mg N-acetylcysteine (group C). The primary outcome measure was the quality of mucosal visualization (score: excellent, adequate or inadequate). Results The addition of simethicone (group B) or simethicone plus N-acetylcysteine to the water (group C) improved the visualization scores of endoscopies compared with water alone (group A). In particular, groups B and C produced a significantly higher percentage of endoscopies with excellent visualization for the esophagus (91.1 % and 86.7 %, respectively, vs. 71.4 % in group A; P < 0.001) and stomach (76.2 % and 74.5 % vs. 38.8 % in group A; P < 0.001). For the duodenum, the use of simethicone also showed an increase in the endoscopies with excellent visualization compared with water alone (85.1 % vs. 73.5 %; P = 0.042). There were no significant differences in scores between groups B and C or between gastric scores in patients with previous subtotal gastrectomy (B and C vs. A): 60.0 % and 42.1 % vs. 28.6 % (P = 0.14). The rate of reported lesions was higher in group B but without statistical significance. Conclusions Premedication with simethicone resulted in better mucosal visibility. Such premedication might improve diagnostic yield, and should be considered for standard practice. Trial registered at ClinicalTrials.gov (NCT02357303).

Health-related quality of life and utilities in gastric premalignant conditions and malignant lesions: a multicentre study in a high prevalence country.

BACKGROUND AND AIMS: A recent review of economic studies relating to gastric cancer revealed that authors use different tests to estimate utilities in patients with and without gastric cancer. Our aim was to determine the utilities of gastric premalignant conditions and adenocarcinoma with a single standardized health measure instrument. METHODS: Cross-sectional nationwide study of patients undergoing upper endoscopy (n=1,434) using the EQ-5D-5L quality of life (QoL) questionnaire. RESULTS: According to EQ-5D-5L, utilities in individuals without gastric lesions were 0.78 (95% confidence interval: 0.76-0.80), with gastric premalignant conditions 0.79 (0.77-0.81), previously treated for gastric cancer 0.77 (0.73-0.81) and with present cancer 0.68 (0.55-0.81). Self-reported QoL according to the visual analogue scale (VAS) for the same groups were 0.67 (0.66-0.69), 0.67 (0.66-0.69), 0.62 (0.59-0.65) and 0.62 (0.54-0.70) respectively. Utilities were consistently lower in women versus men (no lesions 0.71 vs. 0.78; premalignant conditions 0.70 vs. 0.82; treated for cancer 0.72 vs. 0.78 and present cancer 0.66 vs. 0.70). CONCLUSION: The health-related QoL utilities of patients with premalignant conditions are similar to those without gastric diseases whereas patients with present cancer show decreased utilities. Moreover, women had consistently lower utilities than men. These results confirm that the use of a single standardized instrument such as the EQ-5D-5L for all stages of the gastric carcinogenesis cascade is feasible and that it captures differences between conditions and gender dissimilarities, being relevant information for authors pretending to conduct further cost-utility analysis.

Endoscopic mucosal resection of large colorectal polyps: prospective evaluation of recurrence and complications.

BACKGROUND: Endoscopic mucosal resection (EMR) is a major therapeutic advance in the treatment of sessile and flat colorectal polyps. The aim of the study was to prospectively evaluate the success, complications and recurrence with EMR in colon. METHODS: From Jun/2008 to Jan/2012, patients referred for EMR of polyps > or =20 mm were included. Inject and cut EMR technique was used. Rates of complications and recurrence were assessed at 3, 12 and 36 months. RESULTS: From 78 referred polyps, 73 EMR were performed in 71 patients (54% men, 65.8 +/- 10.6 years). Median polyp size was 30 (20; 35) mm, 64.4% sessile and 37% in rectum. Piecemeal removal performed in 863%. Median follow-up time was 12 (7; 15) months. Histological analysis revealed low-grade dysplasia in 51%, high-grade dysplasia in 37%, intramucosal carcinoma in 11% and invasive carcinoma in 1%. The case of invasive carcinoma was referred for surgery. There were 6 complications (8.2%) resolved without surgery : 5.5% of delayed bleeding, 1.4% of post-polypectomy syndrome and 1.4% of perforation. Recurrence was observed in 22.2% at 3 months, 11.1% at 12 months and 0% at 36 months. By logistic regression, a location near the pectinate line (OR 26.13) and a previous history of polypectomy (OR 7.70) became independent factors related to recurrence. CONCLUSIONS: In our experience, EMR was a relatively safe procedure with all complications managed conservatively. We had an acceptable percentage of local recurrence and all cases of recurrence were treated endoscopically.

Diagnostic accuracy of lugol chromoendoscopy in the oesophagus in patients with head and neck cancer.

BACKGROUND AND AIM: patients with head and neck squamous cell malignancies have a higher risk of oesophageal squamous cell carcinomas. Lugol chromoendoscopy in oesophagus is a simple technique with a high diagnostic yield in premalignant lesions. The objective was to analyze its diagnostic accuracy in dysplasia and carcinoma of the oesophagus in high-risk patients. METHODS: prospective study from April/2008 to January/2012 using lugol chromoendoscopy with biopsies of suspicious lugol voiding areas > or = 5 mm. Patients with head and neck malignancies were included, except the ones with iodine allergy, oesophageal varices and contra-indications to standard endoscopy. The reference method was histopathology. RESULTS: 89 patients were enrolled (mean age 62.8 + or - 13.3 years, 87 % men). Primary tumour was located in oropharynx in 37 (41.6 %), in oral cavity in 29 (32.6 %) and in the larynx in 23 (25.8 %) cases. 40.4 % patients had previous treatments and 87 % reported alcohol or tobacco addition. All exams performed without anaesthesia or complications. Nine suspicious lugol voiding areas were observed and biopsied. Histopathological analysis revealed high-grade dysplasia in 2 (2.2 %) and inflammation or normal findings in the others. The sensitivity and specificity for detecting high-grade dysplasia were 100 % and 92 % (95 % CI: 87-97), respectively. Diagnostic accuracy of the test was 92 % (95 % CI: 86-98). CONCLUSION: lugol staining of the oesophagus during endoscopy seems to be a feasible, safe and justified procedure in high-risk populationas it enhances the detection of premalignant lesions.

Diagnostic accuracy of lugol chromoendoscopy in the oesophagus in patients with head and neck cancer

Background and aim: patients with head and neck squamous cell malignancies have a higher risk of oesophageal squamous cell carcinomas. Lugol chromoendoscopy in oesophagus is a simple technique with a high diagnostic yield in premalignant lesions. The objective was to analyze its diagnostic accuracy in dysplasia and carcinoma of the oesophagus in high-risk patients. Methods: prospective study from April/2008 to January/2012 using lugol chromoendoscopy with biopsies of suspicious lugol voiding areas ≥ 5 mm. Patients with head and neck malignancies were included, except the ones with iodine allergy, oesophageal varices and contra-indications to standard endoscopy. The reference method was histopathology. Results: 89 patients were enrolled (mean age 62.8 ± 13.3 years, 87 % men). Primary tumour was located in oropharynx in 37 (41.6 %), in oral cavity in 29 (32.6 %) and in the larynx in 23 (25.8 %) cases. 40.4 % patients had previous treatments and 87 % reported alcohol or tobacco addition. All exams performed without anaesthesia or complications. Nine suspicious lugol voiding areas were observed and biopsied. Histopathological analysis revealed high-grade dysplasia in 2 (2.2 %) and inflammation or normal findings in the others. The sensitivity and specificity for detecting high-grade dysplasia were 100 % and 92 % (95 % CI: 87-97), respectively. Diagnostic accuracy of the test was 92 % (95 % CI: 86-98). Conclusion: lugol staining of the oesophagus during endoscopy seems to be a feasible, safe and justified procedure in high-risk population as it enhances the detection of premalignant lesions (AU)

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