New Generation Express View: An Artificial Intelligence Software Effectively Reduces Capsule Endoscopy Reading Times.

BACKGROUND: Reading capsule endoscopy (CE) is time-consuming. The Express View (EV) (IntroMedic, Seoul, Korea) software was designed to shorten CE video reading. Our primary aim was to evaluate the diagnostic accuracy of EV in detecting significant small-bowel (SB) lesions. We also compared the reading times with EV mode and standard reading (SR). METHODS: 126 patients with suspected SB bleeding and/or suspected neoplasia were prospectively enrolled and underwent SB CE (MiroCam®1200, IntroMedic, Seoul, Korea). CE evaluation was performed in standard and EV mode. In case of discrepancies between SR and EV readings, a consensus was reached after reviewing the video segments and the findings were re-classified. RESULTS: The completion rate of SB CE in our cohort was 86.5% and no retention occurred. The per-patient analysis of sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of EV compared to SR were 86%, 86%, 90%, 81%, and 86%, respectively, before consensus. After consensus, they increased to 97%, 100%, 100%, 96%, and 98%, respectively. The median reading time with SR and EV was 71 min (range 26−340) and 13 min (range 3−85), respectively (p < 0.001). CONCLUSIONS: The new-generation EV shows high diagnostic accuracy and significantly reduces CE reading times.

Small Bowel Capsule Endoscopy and artificial intelligence: First or second reader?

Several machine learning algorithms have been developed in the past years with the aim to improve SBCE (Small Bowel Capsule Endoscopy) feasibility ensuring at the same time a high diagnostic accuracy. If past algorithms were affected by low performances and unsatisfactory accuracy, deep learning systems raised up the expectancy of effective AI (Artificial Intelligence) application in SBCE reading. Automatic detection and characterization of lesions, such as angioectasias, erosions and ulcers, would significantly shorten reading time other than improve reader attention during SBCE review in routine activity. It is debated whether AI can be used as first or second reader. This issue should be further investigated measuring accuracy and cost-effectiveness of AI systems. Currently, AI has been mostly evaluated as first reader. However, second reading may play an important role in SBCE training as well as for better characterizing lesions for which the first reader was uncertain.

Ileocolic invagination in adults: A totally minimally invasive endoscopic and laparoscopic staged approach.

Adult intussusception of the bowel is a rare clinical entity, and its management remains debated. The timing of treatment is not yet standardised, and no guidelines exist. We report a case of an 83-year-old woman presenting to the emergency department of our hospital with a history of increasing abdominal pain in the right iliac fossa. A contrast-enhanced computed tomography scan showed the presence of a large ileocolic intussusception with evidence of the terminal ileus invaginated within the right colon and the ileocolic vessels dragged and trapped into the intussusception. A colonoscopy confirmed the ileocolic invagination with a large right colonic lesion as leading point, and a partial pneumatic (carbon dioxide) and hydrostatic reduction was achieved. Subsequent laparoscopic right colectomy was performed according to oncological principles. A totally minimally invasive approach of this rare condition has been achieved but the literature lacks about the correct management of this entity.

Colon capsule endoscopy and its effectiveness in the diagnosis and management of colorectal neoplastic lesions.

Introduction: Colorectal cancer (CRC) represents a major cause of morbidity and mortality in Western countries. Though colonoscopy is the benchmark for CRC diagnosis and management, other alternatives have been proposed. Colon capsule endoscopy (CCE) was first introduced in 2006 as a non-invasive painless technology that utilizes an ingestible, wireless, and disposable capsule to explore the colon, without sedation or air insufflation. Areas covered: To date, the European Society of Gastrointestinal Endoscopy (ESGE) guidelines consider CCE as an option for average-risk colorectal cancer screening patients and in patients with contraindications or unwilling to undergo colonoscopy and/or with an incomplete colonoscopy. Furthermore, Japan's Pharmaceuticals and Medical Devices Agency (JPMDA) and Food and Drug Administration (FDA) approved the use of CCE in patients unwilling or unable to undergo colonoscopy. Expert commentary: CCE accuracy is nearly comparable to conventional colonoscopy for CRC and significant polyps. Moreover, in the setting of incomplete colonoscopy, CCE was demonstrated to have a higher diagnostic yield for significant polyps and to be better tolerated than CTC. However, the use of CCE is still limited. The lesson coming out is that we should explore new populations that are suitable for colon capsules and for which the colon capsule can be an advantage.

Endoscopic mucosal resection of non-ampullary sporadic duodenal adenomas: a retrospective analysis with long-term follow-up.

OBJECTIVE: We investigate the efficiency of endoscopic mucosal resection (EMR) of non-ampullary sporadic duodenal adenomas (NASDA) in a retrospective analysis with long-term follow-up. METHODS: Consecutive patients undergoing EMR of NASDA between May 2002 and December 2016 were retrospectively identified from an electronic database. Endoscopic follow-up was scheduled after 3, 6 and 12 months for the first year, then yearly for up to five years. RESULTS: EMR of 75 NASDA was performed in 68 patients (56% en-bloc, 44% piecemeal). Retroperitoneal perforations occurred in 3/68 (4.4%) patients, were treated by surgical (n = 2) or percutaneous (n = 1) drainage; delayed bleeding was reported in 13/75 (17.3%) resections and was successfully managed by endoscopy (n = 12) or radiologic embolization (n = 1). There was no procedure-related mortality. Follow-up was available in 61/68 patients (89.7%) after a median time of 59 months from resection. Residual and recurrent adenoma were diagnosed in 9 (14.5%) and 6 (10.9%) cases, respectively; all but one were successfully retreated endoscopically. CONCLUSIONS: EMR for NASDA is effective with a favorable long-term outcome. Local recurrences can be retreated endoscopically. A recall system, patient's compliance to endoscopic follow-up are mandatory to detect recurrences and their prompt treatment.

Real-time diagnosis of H. pylori infection during endoscopy: Accuracy of an innovative tool (EndoFaster).

BACKGROUND: EndoFaster is novel device able to perform real-time ammonium measurement in gastric juice allowing H. pylori diagnosis during endoscopy. This large study aimed to validate the accuracy of EndoFaster for real-time H. pylori detection. METHODS: Consecutive patients who underwent upper endoscopy in two centres were prospectively enrolled. During endoscopy, 4 ml of gastric juice were aspirated to perform automatic analysis by EndoFaster within 90 seconds, and H. pylori was considered present (>62 ppm/ml) or absent (≤62 ppm/ml). Accuracy was measured by using histology as gold standard, and (13)C-urea breath test (UBT) in discordant cases. Accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) were calculated. RESULTS: Overall, 189 patients were enrolled, but in seven (3.4%) the aspirated gastric juice amount was insufficient to perform the test. The accuracy, sensitivity, specificity, PPV, and NPV were 87.4%, 90.3%, 85.5%, 80.2%, 93.1%, respectively, and 92.6%, 97.1%, 89.7%, 85.9%, 98.0%, respectively, when H. pylori status was reclassified according to the UBT result in discordant cases. CONCLUSIONS: This study found a high accuracy/feasibility of EndoFaster for real-time H. pylori diagnosis. Use of EndoFaster may allow selecting those patients in whom routine gastric biopsies could be avoided.

Prognostic variables for the clinical success of flexible endoscopic septotomy of Zenker's diverticulum.

BACKGROUND AND AIMS: Flexible endoscopy septotomy for Zenker's diverticulum (ZD) is an alternative to endostapling; however, long-term data are sparse and studies are heterogeneous. The aim of this study was to assess the clinical success of flexible endoscopy diverticuloscope-assisted septotomy according to all ZD-related symptoms and to identify potential prognostic variables. METHODS: A prospective database of all patients with ZD undergoing septotomy and followed up for 24 months or longer was analyzed. Septotomy was conducted by using a diverticuloscope-assisted technique. Dysphagia, regurgitation, and respiratory symptoms (during the day and at night) were scored by their weekly frequency from 0 to 3 when on a solid food diet. Clinical success (asymptomatic state) was defined as a maximum of 2 symptoms with a score of 1 (once per week). Prognostic variables of clinical success included age, sex, pretreatment total symptom score, pre- and posttreatment ZD size, and septotomy length. The Kaplan-Meier method and Cox proportional hazards model were used to calculate the crude and adjusted hazard ratio (HR). RESULTS: Septotomy was attempted and achieved in a single session in 89 patients. Clinical success at the intention-to-treat analysis was 69%, 64%, and 46% at 6, 24, and 48 months, respectively. Adverse events occurred in 3 patients: perforation in 2 (2%) and postprocedural bleeding in 1 (1%). Independent variables for failure at 6 months were a septotomy length ≤25 mm (HR 6.34) and pretreatment ZD size ≥50 mm (HR 11.08), whereas at 48 months, they were septotomy length ≤25 (HR 2.20) and posttreatment ZD size ≥10 mm (HR 2.03). Success rates for ZD ranging in size from 30 mm to 49 mm with a septotomy >25 mm were 100% and 71% at 6 months and 48 months, respectively. CONCLUSION: Flexible endoscopic septotomy for ZD is feasible and safe. Treatment success correlates with the length of the septotomy and the size of ZD, which should ultimately determine the appropriate approach.

Comparison between loop-tip guidewire-assisted and conventional endoscopic cannulation in high risk patients.

BACKGROUND: The guidewire biliary cannulation (GWC) technique may increase the cannulation rate and decrease the risk for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. The aim of our multicenter prospective randomized controlled trial was to determine if the use of an atraumatic loop-tip guidewire reduces the rate of post-ERCP pancreatitis (PEP) compared with the standard contrast-assisted cannulation (CC) technique. METHODS: From June 2012 to December 2013, a total of 320 patients who had a naïve papilla and were referred for ERCP were randomly assigned to the GWC group (n = 160) or the CC group (n = 160). GWC or CC was randomly used. In cases of failed cannulation in both arms after crossover, biliary access was attempted with alternative techniques (e. g., dual-wire technique, pancreatic duct stenting, precut). RESULTS: The biliary cannulation rates were 81 % in the GWC group and 73 % in the CC group (P = n. s.). Following crossover, cannulation was successful in 8 % and 11 % of patients in the GWC and CC groups, respectively. With use of an alternative technique, the cannulation rates were 98 % in the GWC group and 96 % in the CC group, respectively. The rates of PEP were 5 % in the GWC group and 12 % in the CC group (P = 0.027). The post-interventional complication rates did not differ between the two groups. CONCLUSION: GWC with the new wire guide is associated with a lower rate of PEP in comparison with the CC technique. Clinical trial reference number: NCT01771419.

Current status of device-assisted enteroscopy: Technical matters, indication, limits and complications.

Enteroscopy, defined as direct visualization of the small bowel with the use of a fiberoptic or capsule endoscopy, has progressed considerably over the past several years. The need for endoscopic access to improve diagnosis and treatment of small bowel disease has led to the development of novel technologies one of which is non-invasive, the video capsule, and a type of invasive technique, the device-assisted enteroscopy. In particular, the device-assisted enteroscopy consists then of three different types of instruments all able to allow, in skilled hands, to display partially or throughout its extension (if necessary) the small intestine. Newer devices, double balloon, single balloon and spiral endoscopy, are just entering clinical use. The aim of this article is to review recent advances in small bowel enteroscopy, focusing on indications, modifications to improve imaging and techniques, pitfalls, and clinical applications of the new instruments. With new technologies, the trials and tribulations of learning new endoscopic skills and determining their role in the diagnosis and treatment of small bowel disease come. Identification of small bowel lesions has dramatically improved. Studies are underway to determine the best strategy to apply new enteroscopy technologies for the diagnosis and management of small bowel disease, particularly obscure bleeding. Vascular malformations such as angiectasis and small bowel neoplasms as adenocarcinoma or gastrointestinal stromal tumors. Complete enteroscopy of the small bowel is now possible. However, because of the length of the small bowel, endoscopic examination and therapeutic maneuvers require significant skill, radiological assistance, the use of deep sedation with the assistance of the anesthetist. Prospective randomized studies are needed to guide diagnostic testing and therapy with these new endoscopic techniques.

Increased diagnostic yield of small bowel tumors with PillCam: the role of capsule endoscopy in the diagnosis and treatment of gastrointestinal stromal tumors (GISTs). Italian single-center experience.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are rare tumors, accounting for 1-3% of all gastrointestinal malignancies; they are, however, the most common gastric and small bowel mesenchymal tumors. The length and relative inaccessibility of the small bowel have long constrained the diagnosis of GISTs mainly presenting with chronic or intermittent bleeding as the sole clinical manifestation. AIM: To report on the prevalence of small bowel GISTs in a prospectively recorded series of patients undergoing capsule endoscopy (CE). PATIENTS AND METHODS: Between 2001 and 2007 five hundred patients were referred to our endoscopy unit for small bowel evaluation with capsule endoscopy. We retrospectively evaluated all charts. The main indications for CE were obscure-occult or obscure-overt bleeding. Two hundred eighty-nine patients underwent CE for either obscure-occult or obscure-overt bleeding and 211 for other indications. Patient outcome and care processes were measured by follow-up telephone interviews and chart review. Statistical computations were performed using Fisher's exact test and Student's t-test. RESULTS: CE identified a small bowel tumor in 20 patients (4.0%) and 9 tumors turned out to be GISTs (45.0%). Traditional endoscopic and radiological imaging failed to detect the GIST in all these cases. In one case a small bowel GIST was diagnosed by angiography and CE proved false negative. Overall, CE was able to diagnose a small bowel GIST in 9 out of 10 cases. All patients underwent surgical treatment and showed normalized hemoglobin levels at follow-up. The main limitation of this study is the small number of cases. CONCLUSIONS: CE is an effective and sensitive diagnostic device compared with conventional radiology and plays an important role in the algorithm for the diagnostic work-up of suspected small bowel tumors.

Colon capsule endoscopy: Advantages, limitations and expectations. Which novelties?

Since the first reports almost ten years ago, wireless capsule endoscopy has gained new fields of application. Colon capsule endoscopy represents a new diagnostic technology for colonic exploration. Clinical trials have shown that colon capsule endoscopy is feasible, accurate and safe in patients suffering from colonic diseases and might be a valid alternative to conventional colonoscopy in selected cases such as patients refusing conventional colonoscopy or with contraindications to colonoscopy or when colonoscopy is incomplete. Despite the enthusiasm surrounding this new technique, few clinical and randomized controlled trials are to be found in the current literature, leading to heterogeneous or controversial results. Upcoming studies are needed to prove the substantial utility of colon capsule endoscopy for colon cancer screening, especially in a low prevalence of disease population, and for other indications such as inflammatory bowel disease. Possible perspectives are critically analysed and reported in this paper.

Endoscopic magnetic gastroenteric anastomosis for palliation of malignant gastric outlet obstruction: a prospective multicenter study.

BACKGROUND: Palliation of malignant gastric outlet obstruction remains challenging. Although there are 2 established treatment options, ie, surgical gastrojejunostomy and endoscopic duodenal stent insertion, there is an ongoing search for a technique that would combine the safety and rapid effect of duodenal stent placement with the long-term efficacy and low reintervention rate of a surgical gastrojejunostomy. OBJECTIVE: To investigate the safety and success rate of endoscopic creation of a gastroenteric anastomosis formed by magnetic compression and stent placement. DESIGN: Prospective, multicenter cohort study. SETTING: Four referral centers. PATIENTS: The expected number of patients with symptomatic malignant gastric outlet obstruction to be included at the participating hospitals during a year was 40. Because of a serious adverse device event, the study was terminated after inclusion of 18 patients. INTERVENTION: Creation of an endoscopic gastroenteric anastomosis by using the Cook Magnetic Anastomosis Device with transanastomotic deployment of a self-expandable stent. MAIN OUTCOME MEASUREMENTS: Primary endpoints were safety and success rate associated with the creation of an endoscopic gastrojejunostomy by using a magnetic anastomotic device with transanastomotic deployment of a self-expandable stent. RESULTS: Because of a serious adverse event, the study was terminated prematurely. A success rate of 66.7% (12 of 18 patients) was achieved; 1 serious adverse event (stent perforation) occurred leading to the death of the patient. Three patients (25%) experienced an adverse device effect (stent migration). LIMITATIONS: Small sample size, lack of a control group. CONCLUSION: Endoscopic creation of a gastroenteric anastomosis by magnetic compression is feasible and safe; however, the necessity of a stent led to serious morbidity and even mortality in this study. The current system can therefore not be recommended for clinical use.

Unexplained iron deficiency anaemia: Is it worthwhile to perform capsule endoscopy?

BACKGROUND: In around 30% of iron deficiency anaemia (IDA) cases a definite diagnosis cannot be made. AIM: To investigate the role of capsule endoscopy (CE) in detecting lesions in patients with unexplained IDA after a negative endoscopic, serologic and haematologic diagnostic work up and its possible role in influencing clinical outcome. METHODS: 138 patients suffering from IDA were identified among 650 consecutive patients undergoing CE at our unit. RESULTS: CE revealed the following positive findings in 91/138 patients: angiodysplasias in 51 patients; jejunal and/or ileal micro-ulcerations in 12; tumours/polyps in 9; erosive gastritis in 4; Crohn's disease in 5; jejunal villous atrophy in 5; a solitary ileal ulcer in 1 and active bleeding in the last 4 patients. Follow up data were available for 80/91 patients (87.9%). In 15 out of 46 patients with angiodysplasias IDA spontaneously resolved without any treatment; 9 patients required iron supplementation; 10 patients healed after lanreotide administration; APC was performed in 9 out of 46 patients and 3 patients underwent regular blood transfusion without any success on IDA. 10 out of the 12 patients with small bowel micro-ulcers spontaneously recovered from IDA whilst 2 patients after iron supplementation. All 9 patients affected by tumours/polyps were surgically addressed. In all erosive gastritis cases, patients recovered from IDA after PPI and Helicobacter pylori eradication. Four patients with Crohn's disease diagnosis restored to health with medical therapy. One out of the 4 patients with jejunal villous atrophy and the sole patient with a solitary ileal ulcer spontaneously healed. In 1 out of 3 patients with active bleeding IDA resolved without further treatment after blood transfusion whilst 2 patients were referred for surgical treatment. At follow up, complete resolution of IDA was achieved in 96.25%. CONCLUSIONS: Small bowel investigation is a matter of great importance in IDA patients after negative upper and lower gastrointestinal endoscopy.

Polyethylene glycol plus simethicone in small-bowel preparation for capsule endoscopy.

BACKGROUND: Small-bowel contents can hamper the quality of video-capsule endoscopy (VCE). No standardized protocol has been proposed and overnight fasting remains the proposed preparation for VCE. AIMS: The aim was to evaluate the effects of 2 regimens of bowel preparation on small intestine cleansing, diagnostic yield and capsule transit times. METHODS: This is a prospective, randomized, blinded, and controlled study. Sixty patients referred for VCE were randomized into 2 groups. Group A ingested 2l of a polyethylene glycol and simethicone solution 16h before VCE. Group B were instructed to consume a fibre-free diet and allowed to consume clear liquids the day before VCE. The small-bowel cleansing was graded as "complete" if the entire wall was assessable, "incomplete" if more than 50% of the wall was visible, and "insufficient" if less than 50% of the wall was visible. RESULTS: In group A, a "complete", "incomplete" and "insufficient" small-bowel cleansing was achieved in 42%, 39% and 19% of cases respectively. In group B, a "complete", "incomplete" and "insufficient" small-bowel cleansing was achieved in 43%, 33% and 24% of cases respectively. No significant differences were observed between the two groups, regarding small-bowel cleansing level (p=0.65). No differences were also observed in the diagnostic yield (48.2%, 13.8% and 38% vs 65.5%, 6.9% and 27.6% of positive, suspicious and no findings respectively, in groups A and B [p=0.39]) and small-bowel transit times (mean 288min and 299 min in groups A and B respectively [p=0.70]). CONCLUSIONS: The results of the present study do not support the use of 2l of a polyethylene glycol and simethicone solution before VCE.

Video capsule endoscopy in small-bowel tumours: a single centre experience.

OBJECTIVE: Early diagnosis of small-bowel tumours is crucial for curative surgery. Although videocapsule endoscopy (VCE) has improved the diagnosis of small-bowel diseases, there are few data about the role of this examination in small-bowel malignancies. The aim of this study was to evaluate the diagnostic yield of VCE in small-bowel malignancies. MATERIAL AND METHODS: From March 2001 to July 2006, 380 patients were studied by VCE in our centre. Data on 13 consecutive patients (3.4%) affected by small-bowel malignancy were retrospectively assessed from a prospectively collected database. Indications for VCE were: obscure gastrointestinal bleeding in 9 patients (70%), abdominal pain, coeliac disease, long-lasting fever and hepatic metastasis in the other 4 patients, respectively, (7.5%). Before VCE, patients had undergone 65 procedures, including oesophagogastroduodenoscopy, colonoscopy, push-enteroscopy, small-bowel radiographies, abdominal CT scanning, nuclear medicine bleeding-scan, positron emission tomography and octreoscan. RESULTS: VCE detected jejunal polyps in 6 patients (46.2%), ulcerated stricture in 3 (23%), and erosions, stricture with ileal inflammation, submucosal nodule and active bleeding in 4 patients, respectively. The diagnosis was confirmed after surgery in 11 cases. One patient died of ischaemic myocardial infarction 3 days after VCE, before surgery. Histological examination showed lymphoma (n=3), small-bowel metastasis from colonic carcinoma (n=3), carcinoid tumour (n=3), gastrointestinal stromal tumour (GIST) (n=2), metastatic melanoma (n=1) and primary small-bowel adenocarcinoma (n=1). VCE had an influence on the diagnosis or management of 10/13 patients. CONCLUSIONS: VCE is the diagnostic test with the highest yield for small-bowel malignancies, since it can detect small-bowel tumours that are often missed by traditional examinations.