Interobserver agreement on landmark and flexure identification in colon capsule endoscopy.

PURPOSE: When an optical colonoscopy is carried out, Scope Guide can assist the endoscopist in determining the localization. In colon capsule endoscopy (CCE), this support is not available. To our knowledge, the interobserver agreement on landmark identification has never been studied. This study aims to investigate the interobserver agreement on landmark identification in CCE. METHODS: An interobserver study was carried out comparing the landmark identification (the ileocecal valve, hepatic flexure, splenic flexure, and anus) in CCE investigations between an external private contractor and three in-house CCE readers with different levels of experience. All CCE investigations analyzed in this study were carried out as a part of the Danish screening program for colorectal cancer. Patients were between 50 and 74 years old with a positive fecal immunochemical test (FIT). A random sample of 20 CCE investigations was taken from the total sample of more than 800 videos. RESULTS: Overall interobserver agreement on all landmarks was 51%. Interobserver agreement on the first cecal image (ileocecal valve), hepatic flexure, splenic flexure, and last rectal image (anus) was 72%, 29%, 22%, and 83%, respectively. The overall interobserver agreement, including only examinations with adequate bowel preparation (n = 16), was 54%, and for individual landmarks, 73%, 32%, 24%, and 85%. CONCLUSION: Overall interobserver agreement on all four landmarks from CCE was poor. Measures are needed to improve landmark identification in CCE investigations. Artificial intelligence could be a possible solution to this problem.

Edge artificial intelligence wireless video capsule endoscopy.

Gastrointestinal (GI) tract diseases are responsible for substantial morbidity and mortality worldwide, including colorectal cancer, which has shown a rising incidence among adults younger than 50. Although this could be alleviated by regular screening, only a small percentage of those at risk are screened comprehensively, due to shortcomings in accuracy and patient acceptance. To address these challenges, we designed an artificial intelligence (AI)-empowered wireless video endoscopic capsule that surpasses the performance of the existing solutions by featuring, among others: (1) real-time image processing using onboard deep neural networks (DNN), (2) enhanced visualization of the mucous layer by deploying both white-light and narrow-band imaging, (3) on-the-go task modification and DNN update using over-the-air-programming and (4) bi-directional communication with patient's personal electronic devices to report important findings. We tested our solution in an in vivo setting, by administrating our endoscopic capsule to a pig under general anesthesia. All novel features, successfully implemented on a single platform, were validated. Our study lays the groundwork for clinically implementing a new generation of endoscopic capsules, which will significantly improve early diagnosis of upper and lower GI tract diseases.

Point-of-care ultrasound of the heart and lungs in patients with respiratory failure: a pragmatic randomized controlled multicenter trial.

BACKGROUND: Point-of-care ultrasound is a focus oriented tool for differentiating among cardiopulmonary diseases. Its value in the hands of emergency physicians, with various ultrasound experience, remains uncertain. We tested the hypothesis that, in emergency department patients with signs of respiratory failure, a point-of-care cardiopulmonary ultrasound along with standard clinical examination, performed by emergency physicians with various ultrasound experience would increase the proportion of patients with presumptive diagnoses in agreement with final diagnoses at four hours after admission compared to standard clinical examination alone. METHODS: In this prospective multicenter superiority trial in Danish emergency departments we randomly assigned patients presenting with acute signs of respiratory failure to intervention or control in a 1:1 ratio by block randomization. Patients received point-of-care cardiopulmonary ultrasound examination within four hours from admission. Ultrasound results were unblinded for the treating emergency physician in the intervention group. Final diagnoses and treatment were determined by blinded review of the medical record after the patients´ discharge. RESULTS: From October 9, 2015 to April 5, 2017, we randomized 218 patients and included 211 in the final analyses. At four hours we found; no change in the proportion of patients with presumptive diagnoses in agreement with final diagnoses; intervention 79·25% (95% CI 70·3-86·0), control 77·1% (95% CI 68·0-84·3), an increased proportion of appropriate treatment prescribed; intervention 79·3% (95% CI 70·3-86·0), control 65·7% (95% CI 56·0-74·3) and of patients who spent less than 1 day in hospital; intervention n = 42 (39·6%, 25·8 38·4), control n = 25 (23·8%, 16·5-33·0). No adverse events were reported. CONCLUSIONS: Focused cardiopulmonary ultrasound added to standard clinical examination in patients with signs of respiratory failure had no impact on the diagnostic accuracy, but significantly increased the proportion of appropriate treatment prescribed and the proportion of patients who spent less than 1 day in hospital. TRIAL REGISTRATION: https://clinicaltrials.gov/ , number NCT02550184 .

Colon capsule endoscopy versus CT colonography after incomplete colonoscopy. Application of artificial intelligence algorithms to identify complete colonic investigations.

BACKGROUND: Guidelines suggest computed tomography colonography (CTC) following incomplete optical colonoscopy (OC). Colon capsule endoscopies (CCE) have been suggested as an alternative, although completion rates have been unsatisfactory. Introduction of artificial intelligence (AI)-based localization algorithms of the camera capsules may enable identification of incomplete CCE investigations overlapping with incomplete OCs. OBJECTIVE: The study aims to investigate relative sensitivity of CCE compared with CTC following incomplete OC, investigate the completion rate when combining results from the incomplete OC and CCE, and develop a forward-tracking algorithm ensuring a safe completeness of combined investigations. METHODS: In this prospective paired study, patients with indication for CTC following incomplete OC were included for CCE and CTC. Location of CCE abortion and OC abortion were registered to identify complete combined investigations. AI-based algorithm for localization of capsules were developed reconstructing the passage of the colon. RESULTS: In 237 individuals with CTC indication; 105 were included, of which 97 underwent both a CCE and CTC. CCE was complete in 66 (68%). Including CCEs which reached most oral point of incomplete OC, 73 (75%) had complete colonic investigations; 78 (80%) had conclusive investigations. Relative sensitivity of CCE compared with CTC was 2.67 (95% confidence interval (CI) 1.76;4.04) for polyps >5 mm and 1.91 (95% CI 1.18;3.09) for polyps >9 mm. An AI-based algorithm was developed. CONCLUSION: Sensitivity of CCE following incomplete OC was superior to CTC. Introducing and improving algorithm-based localization of capsule abortion may increase identification of overall complete investigation rates following incomplete OC.ClinicalTrials.gov identifier: NCT02826993.

Correlation of anorectal manometry measures to severity of fecal incontinence in patients with anorectal malformations - a cross-sectional study.

Anorectal malformations (ARM) are a spectrum of anomalies of the rectum and anal canal affecting 1 in 2500 to 5000 live births. Functional problems are common and related to the type of ARM and associated malformations. We aimed to evaluate the results of Three-dimensional High Resolution Anorectal Manometry (3D-HRAM) in long-term follow-up after surgical correction of ARM with special reference to fecal incontinence. Twenty-one patients with anorectal malformations and primary repair at our center consented to participate in the study. Pressures of the anal sphincter muscles and defects were addressed by 3D-HRAM. Fecal incontinence and disease-specific quality of life were evaluated by the Fecal Incontinence Quality of Life score and Wexner incontinence score respectively. The study was approved by the Committee in Health Research Ethics and the Danish Data Protection Agency. Median age was 22(12-31) years and 13(67%) participants were females. Sphincter defect was present in 48% (N = 10) of participants. Participants with sphincter defects had significant higher Wexner score and size of sphincter defects and mean anal squeeze pressure were correlated to Wexner score. Participants with or without sphincter defects did not differ on manometry parameters including resting anal and squeeze pressure or disease-specific quality of life. In a study of the long-term outcome after repair of anorectal malformations we found a higher Wexner incontinence score in the presence of an anal sphincter defect and the size of the defect and mean anal squeeze pressure were correlated to the Wexner incontinence score.

Diagnostic value of whole-body-focused ultrasonography in high-acuity patients in the emergency department: a prospective single-center cross-sectional study.

BACKGROUND: A fast and diagnostic accurate tool to assess the unselected category of high-acuity patients, in whom the underlying pathology is not always obvious, is needed in the emergency departments (ED). We aim to describe the feasibility, validity and diagnostic yield of a routine whole-body-focused ultrasonography (wbf-us) in an unselected group of high-acuity ED patients. METHODS: In a prospective observational study, a convenience sample of ED patients (≥ 18 years) with a high-acuity score or systolic blood pressure < 100 mmHg received a routine wbf-us of the heart, lungs, abdomen and deep veins by two non-expert sonographers. Final diagnosis was established by experienced auditors. Investigators were blinded to the patients' medical history and emergency physicians and auditors were blinded to the investigators assessments. Diagnostic accuracy was assessed by comparing the investigators' ultrasonography findings to a structured double-blinded clinical audit of patient files. RESULTS: We included 171 patients, initiated a whole-body-focused ultrasonography examination (wbf-us) in 160 and completed it in 128 patients with an average time of a full examination of 28 min. We found pathology in 65/171 (38%) of the patients whose most frequent symptoms upon arrival were cardiopulmonary. Among the patients who received wbf-us, we found the majority of pathology by wbf-us of the lungs (n = 50, 31%), the heart (n = 26, 16%), few in the abdomen (n = 5, 3%) and none in the deep veins. The overall sensitivity was 50-100%, specificity 84-94%, positive predictive value 11-44% and negative predictive value 94-100%. CONCLUSION: Focused cardiopulmonary ultrasonography might be considered for routine use in high-acuity ED patients with cardiopulmonary symptoms whereas focused ultrasonography of the abdomen and deep veins performed by non-expert sonographers only seems indicated in selected patients. Trial registration Danish Data Protection Agency (ID 13/12076). Committee on Biomedical Research Ethics for the Region of Southern Denmark (ID S-20130047).

Colon capsule endoscopy for colonic surveillance.

AIM: Resources used in surveillance colonoscopies are taking up an increasing proportion of colonoscopy capacity. Colon capsule endoscopy (CCE) is a promising technique for noninvasive investigation of the colon. We aimed to investigate CCE as a possible filter in colonic surveillance with the primary outcome of reducing the number of colonoscopies. METHOD: Patients scheduled for follow-up colonoscopy were subjected to a primary CCE and only supplemental conventional endoscopy if significant pathology was detected or if the CCE examination was incomplete. Significant pathology was defined as more than two small polyps, or one polyp greater than 9 mm or any polyp in patients with hereditary nonpolyposis colorectal cancer. Supplemental endoscopy was carried out to the extent needed to resect the detected polyps and investigate the parts of the colon that were not sufficiently visualized by the capsule. RESULTS: A total of 180 patients were included. Seventy-seven patients (43%) had a complete CCE with no significant findings. A complete colonoscopy was carried out in 67 patients (37%) and 36 patients (20%) underwent a sigmoidoscopy. In the 103 patients undergoing endoscopy, 59 (57%) had no adenomas detected, 33 (32%) had 'low-risk' adenomas and 11 (11%) had 'high-risk' adenomas. CONCLUSION: The introduction of CCE as filter test in colonic surveillance reduced colonoscopies by 43%, but this implies that untreated polyps are left behind and is not cost-effective. The CCE completion rate must be improved.

Increased Rate of Incidental Colorectal Malignant Polyps: A Single-Center Experience.

BACKGROUND AND AIMS: To investigate the incidence and treatment of colorectal malignant polyps before and after colorectal cancer screening initiation in March 2014 in a single Danish center. MATERIALS AND METHODS: 71 patients with colorectal malignant polyps in a single center from 2012 to 2015 were reported retrospectively. RESULTS: There was a significant increase (P < 0.01) in the incidence of colorectal malignant polyps from 2012 to 2013 and 2014 to 2015 (8 versus 63) relative to the increase in colonoscopies with polypectomy (1029 versus 2706). It coincides with the initiation of screening in March 2014. A positive, nonradical, or undeterminable resection margin was found in 57% (36/63), and this was the primary indication for surgery. Additional surgery was done in 49% of the cases (31/63) with 27 bowel resections and 4 transanal endoscopic microsurgery (TEM) procedures. Nineteen percent (5/27) had either residual cancer cells at the polypectomy site or lymph node metastasis in the resection specimens. CONCLUSION: Colorectal malignant polyps have become more frequent after the initiation of screening. The primary, and operator-dependent, indicator for surgery is the positive, nonradical, or undeterminable resection margin, and 1 in 5 operated has remaining cancer in the resection specimens.

Back-to-back colon capsule endoscopy and optical colonoscopy in colorectal cancer screening individuals.

AIM: The aim was to determine the polyp detection rate and per-patient sensitivity for polyps > 9 mm of colon capsule endoscopy (CCE) compared with colonoscopy as well as the diagnostic accuracy of CCE. METHOD: Individuals who had a positive immunochemical faecal occult blood test during screening had investigator blinded CCE and colonoscopy. Participants underwent repeat endoscopy if significant lesions detected by CCE were considered to have been missed by colonoscopy. RESULTS: There were 253 participants. The polyp detection rate was significantly higher in CCE compared with colonoscopy (P = 0.02). The per-patient sensitivity for > 9 mm polyps for CCE and colonoscopy was 87% (95% CI: 83-91%) and 88% (95% CI: 84-92%) respectively. In participants with complete CCE and colonoscopy examinations (N = 126), per-patient sensitivity of > 9 mm polyps in CCE (97%; 95% CI: 94-100%) was superior to colonoscopy (89%; 95% CI: 84-94%). A complete capsule endoscopy examination (N = 134) could detect patients with intermediate or greater risk (according to the European guidelines) with an accuracy, sensitivity, specificity and positivity rate of 79%, 93%, 69% and 58% respectively, using a cut-off of at least one polyp > 10 mm or more than two polyps. CONCLUSION: CCE is superior to colonoscopy in polyp detection rate and per-patient sensitivity to > 9 mm polyps, but only in complete CCE examinations. The rate of incomplete CCE examinations must be improved.

The Diagnostic Yield of Colonoscopy Stratified by Indications.

INTRODUCTION: Danish centers reserve longer time for screening colonoscopies and allocate the most experienced endoscopists to these cases. The objective of this study is to determine the diagnostic yield in colonoscopies for different indications to improve planning of colonoscopy activity and allocation of the highly skilled endoscopists. METHODS: Nine hundred and ninety-nine randomly collected patients from a prospectively maintained database were grouped in defined referral indication groups. Five groups were compared in respect of the detection rate of adenomas and cancers. RESULTS: Two hundred and eighty-nine of 1098 colonoscopies in 999 patients showed significant neoplastic findings, resulting in 591 adenoma resections. Eighty-five percent were treated with a snare resection, and 15% with endoscopic mucosa resection (EMR). Positive findings in the indication groups were (1) symptoms, 25%; (2) positive screening, 17%; (3) previous resection of adenomas, 45%; (4) previous resection of colorectal cancer, 15%; and (5) surveillance of patients with high-risk family history of cancer, 35%. CONCLUSION: The majority of adenomas found during colonoscopy can be treated with simple techniques. If individualized time slots are considered, the adenoma follow-up colonoscopies are likely to be the most time-consuming group with more than twice the number of adenomas detected as compared to other indications.

Dual-energy CT can detect malignant lymph nodes in rectal cancer.

BACKGROUND: There is a need for an accurate and operator independent method to assess the lymph node status to provide the most optimal personalized treatment for rectal cancer patients. This study evaluates whether Dual Energy Computed Tomography (DECT) could contribute to the preoperative lymph node assessment, and compared it to Magnetic Resonance Imaging (MRI). The objective of this prospective observational feasibility study was to determine the clinical value of the DECT for the detection of metastases in the pelvic lymph nodes of rectal cancer patients and compare the findings to MRI and histopathology. MATERIALS AND METHODS: The patients were referred to total mesorectal excision (TME) without any neoadjuvant oncological treatment. After surgery the rectum specimen was scanned, and lymph nodes were matched to the pathology report. Fifty-four histology proven rectal cancer patients received a pelvic DECT scan and a standard MRI. The Dual Energy CT quantitative parameters were analyzed: Water and Iodine concentration, Dual-Energy Ratio, Dual Energy Index, and Effective Z value, for the benign and malignant lymph node differentiation. RESULTS: DECT scanning showed statistical difference between malignant and benign lymph nodes in the measurements of iodine concentration, Dual-Energy Ratio, Dual Energy Index, and Effective Z value. Dual energy CT classified 42% of the cases correctly according to N-stage compared to 40% for MRI. CONCLUSION: This study showed statistical difference in several quantitative parameters between benign and malignant lymph nodes. There were no difference in the accuracy of lymph node staging between DECT and MRI.

Focused ultrasound examination of the chest on patients admitted with acute signs of respiratory problems: a study protocol for a pragmatic randomised controlled multicentre trial.

INTRODUCTION: Patients with acute respiratory problems poses a diagnostic challenge because similar symptoms can be caused by various pathological conditions. Focused ultrasound examination (f-US) of the heart and lungs has proven to increase the diagnostic accuracy in these patients. In this protocol of a randomised multicentre trial, we study the effect of f-US of the heart and lungs in patients with respiratory problems performed by emergency physicians (EP) as soon as the patient arrives to the emergency department (ED). The primary outcome is the number of patients with a correct presumptive diagnosis at 4 hours from admission. METHODS AND ANALYSIS: This is a semiblinded randomised prospective study. 288 patients will be included and randomised into the control or intervention group. All patients receive a standard diagnostic evaluation by the EP to assess the primary presumptive diagnosis. Investigators are EP, with varying degrees of experience in f-US, who perform an f-US of the heart and lungs in patients in both treatment arms. f-US results in the intervention group are non-blinded to the treating EP to be included in the assessment of the 4-hour presumptive diagnosis. As standard for correct diagnosis, we perform a blinded journal audit after discharge. As primary analysis, we use the intention-to-treat analysis. CONCLUSIONS: This study is the first multicentre trial in EDs to investigate whether f-US, in the hands of the EP, increases the proportion of correct diagnosis at 4 hours after arrival when performed on patients with respiratory problems. ETHICS AND DISSEMINATION: This trial is conducted in accordance with the Helsinki II Declaration and approved by the Danish Data Protection Agency and the Committee on Biomedical Research Ethics for the Region of Southern Denmark. Results will be published in accordance with the CONSORT statement in a peer-reviewed scientific journal regardless of the outcome. TRIAL REGISTRATION NUMBER: NCT02550184; Pre-results.

Differentiation of Metastatic and Non-Metastatic Mesenteric Lymph Nodes by Strain Elastography in Surgical Specimens.

PURPOSE: To investigate if strain elastography could differentiate between metastatic and non-metastatic mesenteric lymph nodes ex-vivo. MATERIALS AND METHODS: 90 mesenteric lymph nodes were examined shortly after resection from 25 patients including 17 patients with colorectal cancer and 8 patients with Crohn's disease. Ultrasound-based strain elastography was performed with a linear probe. Tissue hardness in lymph nodes was assessed using visual scales and measuring the strain ratio. B-mode characteristics were also recorded. Pathological diagnosis with grading of fibrosis served as the reference standard. RESULTS: 20 lymph nodes were metastatic and 70 lymph nodes were non-metastatic. The strain ratios of metastatic and non-metastatic lymph nodes were significantly different (1.83 vs. 1.42, p = 0.021). The VAS scale (0 - 100) for tissue hardness gave higher mean values for metastatic than non-metastatic nodes, but the difference was not significant (65.5 vs. 55.0, p = 0.055). There was no difference between lymph nodes in Crohn's and non-metastatic cancer specimens. The metastatic lymph nodes were significantly more fibrotic than the non-metastatic lymph nodes by the ordinal fibrosis score (0 - 3). In an ROC analysis, quantitative strain imaging was not superior to the measurement of the short-axis diameter of lymph nodes in differentiating metastatic from non-metastatic mesenteric lymph nodes ex-vivo. CONCLUSION: Strain elastography is correlated to fibrosis in lymph nodes and a significant difference was observed on a group level using the strain ratio. Due to measurement overlap, individual mesenteric lymph nodes could not be identified accurately as metastatic or not in this ex-vivo model by strain imaging alone.

Combined endorectal ultrasonography and strain elastography for the staging of early rectal cancer.

AIM: Strain elastography is a novel approach to rectal tumour evaluation. The primary aim of this study was to correlate elastography to pT stages of rectal tumours and to assess the ability of the method to differentiate rectal adenomas (pT0) from early rectal cancer (pT1-2). Secondary aims were to compare elastography with endorectal ultrasonography (ERUS) and to propose a combined strain elastography and ERUS staging algorithm. METHOD: In all, 120 consecutive patients with a suspected rectal tumour were examined in this staging study. Patients receiving surgery without neoadjuvant radiotherapy were included (n = 59). All patients were examined with ERUS and elastography. Treatment decisions were made by multidisciplinary team (MDT) assessment, without considering the strain elastography examination. RESULTS: Histopathology identified 21 adenomas, 13 pT1, 9 pT2, 15 pT3 and one pT4. Mean elastography strain ratios were predictive of T stage (P = 0.01). Differentiation of adenomas from early rectal cancer (pT1-2) had sensitivity, specificity and accuracy of 0.82, 0.86 and 0.84 for elastography and 0.82, 0.62 and 0.72 for ERUS. A combined staging algorithm was developed to identify tumours eligible for local resection. Based on MDT evaluation 32% of tumours later identified as pT0 or pT1 were treated with total mesorectal excision, even though a local excision might have sufficed. Combined ERUS and elastography evaluation would have significantly reduced this number to 9% (P = 0.008). CONCLUSION: Elastography may improve the staging of adenomas and early rectal cancer compared with ERUS alone. Combined ERUS and elastography assessment is likely to further improve the selection of patients for local resection.

Endorectal ultrasonography, strain elastography and MRI differentiation of rectal adenomas and adenocarcinomas.

AIM: Strain elastography is a method for recording tissue hardness. Strain in different areas may be compared using strain ratio (SR). The aims of this study were to validate a previously proposed SR cut-off value of 1.25 for differentiating adenocarcinomas from adenomas and to compare the performance of endorectal ultrasonography (ERUS), strain elastography and MRI in the same patients. METHOD: A prospective evaluation of 120 consecutive patients with rectal neoplasia, using a predetermined elastography strain ratio cut-off value, was performed to differentiate adenomas from adenocarcinomas. ERUS and MRI were performed according to standard routine at Haukeland University Hospital, defining T0 as adenomas and T1-T4 as adenocarcinomas. Subsequent histopathology was used as the reference standard. RESULTS: Histopathological evaluation revealed 21 adenomas and 99 adenocarcinomas. Sensitivity, specificity and accuracy (with 95% CI) were as follows: ERUS: 0.96 (0.90-0.99), 0.62 (0.40-0.80) and 0.90 (0.83-0.94); elastography SR: 0.96 (0.90-0.99), 0.86 (0.66-0.96) and 0.94 (0.88-0.97); and MRI: 0.99 (0.94-1.00), 0.07 (0.00-0.31) and 0.87 (0.80-0.93). CONCLUSION: This study confirms that the elastography SR assessment accurately differentiates sessile adenomas from adenocarcinomas. SR assessment has a superior ability to differentiate adenomas and adenocarcinomas when compared with ERUS and MRI. MRI examination seems unable to recognize adenomas and should be interpreted with care when early-stage rectal neoplasia is suspected.

Cytokine response in peripheral blood indicates different pathophysiological mechanisms behind anastomotic leakage after low anterior resection: a pilot study.

BACKGROUND: Anastomotic leakage (AL) after rectosigmoid resection is a serious complication associated with high morbidity and mortality. This case-control pilot study investigated the changes in blood concentration of 10 different cytokines and 2 complement factors in relation to symptomatic AL after low anterior resection for rectosigmoid cancer. METHODS: Fifty patients scheduled for resection of rectosigmoid cancer had blood samples taken the day before surgery and on post-operative days 1, 3 and 5. Four patients with symptomatic AL were identified. Twenty-two age- and disease-matched patients constituted the control group. The concentration of 10 cytokines (granulocyte macrophage colony-stimulating factor, interferon-γ, interleukin-1ß, interleukin-2, interleukin-4, interleukin-5, interleukin-6, interleukin-8, interleukin-10 and tumour necrosis factor-α) and 2 complement factors (mannan-binding lectin and membrane attack complex) were measured. RESULTS: The present study demonstrated that plasma concentration of interleukin-1ß, interleukin-6, interleukin-8 and interleukin 10 within the first 5 post-operative days was increased in patients who developed early clinical AL, whereas there were no changes in patients with late-onset AL. CONCLUSIONS: The demonstrated differences in the cytokine response in early and late AL may support the theory of different pathological mechanisms of AL.

Strain assessment in surgically resected inflammatory and neoplastic bowel lesions.

PURPOSE: To investigate whether ultrasound-based strain imaging can discriminate between colorectal adenocarcinomas and stenotic Crohn's lesions in newly resected surgical specimens. MATERIALS AND METHODS: Resected surgical specimens from 27 patients electively operated for colorectal tumors or stenotic lesions from Crohn's disease were prospectively examined with ultrasonography using a Hitachi HV 900 US scanner with real-time elastography (RTE). Three different methods were applied to assess tissue strain: A four-level categorical visual classification, a continuous visual analog scale (VAS, 0 - 100) and a strain ratio (SR) measurement between the lesion and surrounding reference tissue. The imaged sections were marked and subsequently examined by a pathologist. Results from RTE were evaluated according to diagnosis, degree of fibrosis, inflammatory parameters, tumor stage and grade. RESULTS: 16 sections from Crohn's lesions, 18 sections from adenocarcinomas and 4 sections from adenomas were examined. Both adenocarcinomas and Crohn's lesions were found to be harder than the surrounding tissue, but they could not be discriminated from each other by any of the strain imaging evaluation methods. All adenocarcinomas had significantly higher strain ratios than adenomas. The categorical classification differentiated poorly between Crohn's lesions, adenocarcinomas and adenomas. Categorical evaluation and VAS score showed fair interobserver agreement. SR measurements provided semi-quantitative strain data and added improved information about elasticity properties, despite substantial intra-observer variation. CONCLUSION: Sonoelastography with SR measurements and visual evaluation of strain differences could not differentiate stenotic Crohn's lesions from adenocarcinomas in resected bowel specimens. A small number of adenomas were found to be significantly softer than adenocarcinomas using the same evaluation methods. The tumor stage or grade did not have a significant impact on the elastography results.

Endorectal elastography in the evaluation of rectal tumours.

AIM: Real-time elastography visualizes tissue compliance using an ultrasound platform. Elastography has been used, particularly in the breast, to characterize indeterminate lesions on B-mode imaging as either benign or malignant. The primary aim of this study was to assess the feasibility of routine endorectal elastography to evaluate rectal neoplasia. The secondary aim was to correlate elastography data with histopathological end-points. METHOD: Sixty-nine patients referred to the outpatient clinic of the Department of Colorectal Surgery at Haukeland University Hospital for the evaluation of rectal tumours were included in this prospective cohort study. All patients underwent digital rectal examination, rigid rectoscopy with biopsy, endorectal ultrasonography and endorectal elastography. In each case a strain ratio was calculated, comparing the tumour tissue with adjacent reference tissue that appeared normal on ultrasound scanning. RESULTS: Histopathologically there were 23 adenomas and 45 adenocarcinomas. One patient died before surgical treatment. Adequate elastography images were obtained in 66/69 (96%) patients. Optimal discrimination of malignant and benign lesions was obtained using a strain ratio cut-off value of 1.25 (sensitivity, 0.93; specificity, 0.96; and accuracy, 0.94). CONCLUSION: Endorectal elastography can be performed as an integral part of the clinical evaluation of rectal tumours and has good patient compliance. The method is a promising modality for the discrimination between adenocarcinoma and adenoma of the rectum.

Logistics and outcome in urgent and emergency colorectal surgery.

AIM: Infrastructure-related factors are seldom described in detail in studies on outcome after surgical procedures. We studied patient, procedure, physician and infrastructure characteristics and their effect on outcome at a Norwegian University hospital. METHOD: All patients admitted between 1st January 2002 and 30th June 2003 who underwent urgent or emergency colorectal surgery were extracted from the hospital databases and retrospectively analysed. RESULTS: There were 196 patients. The overall complication rate was 39%. Forty-six (24%) patients died during admission after surgery. Those who died were less likely to be operated by a subspecialized colorectal surgeon (17%vs 30%, P = 0.001). The anaesthesiologist was a resident in most of the cases (> 75%) for both those who survived and those who died. Surgery performed out-of-office hours was common in both groups, although the patients who died were more likely to be operated upon at night (28%vs 18%, P = 0.001). The time interval standard from admission to surgery was met in only 84 (43%) patients. Forty-nine (49/196, 25%) procedures were delayed beyond the time requested by the surgeon by more than 120 min (mean 363 min). CONCLUSION: The outcome after emergency colorectal surgery was consistent with the literature but the infrastructure was not optimal. Improvements may be achieved by a focus on decreasing waiting times, abandoning of out-of-office emergency surgery and increasing the involvement of senior staff.