Esophageal capsule endoscopy in patients with suspected esophageal disease: double blinded comparison with esophagogastroduodenoscopy and assessment of interobserver variability

BACKGROUND AND STUDY AIMS

The study aim was to compare the diagnostic yield of capsule endoscopy and esophagogastroduodenoscopy (EGD) in patients with suspected esophageal disease. Secondary aims were to assess interobserver variability of capsule endoscopy readings and safety.

PATIENTS AND METHODS

In total, 98 patients (53 men, 53 +/- 13 years) with an indication for EGD were included. The patient population was artificially enriched to include two thirds of patients with abnormal esophageal findings at EGD, which was followed by capsule endoscopy. Capsule recordings were blindly read by three endoscopists, one from the center that recruited the patient and two from the other center. Study outcomes were the findings described on EGD and capsule endoscopy, agreement between EGD and capsule endoscopy for findings, quality of the capsule recording, and interobserver agreement for capsule endoscopy quality and findings.

RESULTS

EGD was normal in 34 patients and showed esophageal findings in 62 (esophagitis 28, hiatus hernia 21, varices 21, Barrett's esophagus 11, others 7). Average esophageal transit time of the capsule was 361 +/- 393 seconds. Capsule endoscopy was normal in 36 patients but detected esophagitis in 23, hiatus hernia in 0, varices in 23, Barrett's esophagus in 18, and others in 4. The positive predictive value of capsule endoscopy was 80.0 % and the negative predictive value was 61.1 %. Overall agreement per patient was moderate between EGD and capsule endoscopy for the per-patient (kappa = 0.42) and per-findings (kappa = 0.40) analyses. Interobserver agreement between capsule endoscopy readings was moderate for findings (kappa = 0.39) and quality assessment (kappa = 0.24). No adverse event was observed after either EGD or capsule endoscopy.

CONCLUSION

In this study, despite artificial prevalence enrichment, capsule endoscopy showed a moderate sensitivity and specificity in the detection of esophageal diseases.

Evaluation of endocytoscopy in the surveillance of patients with Barrett's esophagus

BACKGROUND AND STUDY AIMS

Surveillance for patients with Barrett's esophagus is time consuming and subject to sampling error. Guided biopsies from neoplastic areas invisible on conventional endoscopy may increase effectiveness of surveillance examination. We assessed the accuracy of endocytoscopy in correlation with histology.

METHODS

We analyzed 166 biopsy sites from 16 patients (13 male, mean age 62.1 years), without visible lesions, who presented for Barrett surveillance. Endocytoscopy images were recorded from pre-marked areas in the Barrett's segment using magnification x 1125 or x 450. Biopsies were taken from the same area to allow precise comparison with histology. Image sequences of each area were individually and blindly reviewed by a pathologist and a gastroenterologist. Major outcome variables included image quality, identification of neoplastic characteristics, and accuracy of endocytoscopy.

RESULTS

Adenocarcinoma was histologically diagnosed in 4.2% of biopsy sites, high grade intraepithelial neoplasia (HGIN) in 16.9%, and low grade intraepithelial neoplasia (LGIN) in 12.1 %. Adequate assessment of endocytoscopy images was impossible in 49% of the pre-marked areas with magnification x 450 and in 22% with magnification x 1125. At most, 23% of images with lower magnification were interpretable to identify characteristics of neoplasia, and 41% with higher magnification. Interobserver agreement was fair at best (kappa from < 0 to 0.45). Positive and negative predictive values for HGIN or cancer were 0.29 and 0.87, respectively, for magnification x 450 and 0.44 and 0.83, respectively, for magnification x 1125.

CONCLUSION

When not supported by macroscopic evidence, endoscopic histology using endocytoscopy lacks sufficient image quality to be currently of assistance in identifying neoplastic areas.

Colonoscopy and polypectomy with a side-viewing endoscope

BACKGROUND AND STUDY AIMS

Some colorectal polyps cannot be adequately viewed using forward-viewing colonoscopes because of their location behind mucosal folds or bends in the bowel. We performed polypectomy using side-viewing duodenoscopes for these problematic polyps in order to avoid incomplete polypectomy or the need for surgical intervention.

PATIENTS AND METHODS

Between April 2000 and August 2003, polypectomy with a side-viewing endoscope was intended in 15 patients (seven men, eight women; mean age 63.7 years, median age 59 years, range 38-88 years) at our institution. In all these patients, polypectomy had been attempted previously with a forward-viewing colonoscope by at least one experienced endoscopist without success. The duodenoscope was advanced with slight bending of the tip to achieve a sloped forward view.

RESULTS

Colorectal polyps were macroscopically completely removed in 11/15 patients. One polyp near the ileocecal valve could only be partially removed with the side-viewing endoscope; and one large flat rectal adenoma, one recurrent rectal polyp (after a previous incomplete conventional polypectomy), and one polyp near the ileocecal valve could not be removed. We observed no procedure-related complications. Endoscopic follow-up was possible in seven of the 11 patients in whom the polyps were successfully resected, with no evidence of recurrence (mean follow-up 27 months).

CONCLUSIONS

Polypectomy with the side-viewing duodenoscope is a safe and effective method. It is a therapeutic option when polyps are not adequately accessible using a conventional approach.

Highlights of United European Gastroenterology Week 2006

The United European Gastroenterology Week (UEGW) of 2006 offered an interesting variety of topics, and included many randomized studies that had not been previously presented at major meetings. Papers presented at plenary sessions will be given some priority in the following paper, whereas the selection of topics from abstracts, on the basis of poster presentations, has been more limited, necessarily reflecting to some extent the personal taste of the reviewer.

Prospective study on bright lumen magnetic resonance colonography in comparison with conventional colonoscopy

The aim of this prospective trial was to evaluate sensitivity and specificity of bright lumen magnetic resonance colonography (MRC) in comparison with conventional colonoscopy (CC). A total of 120 consecutive patients with clinical indications for CC were prospectively examined using MRC (1.5 Tesla) which was then followed by CC. Prior to MRC, the cleansed colon was filled with a gadolinium-water solution. A 3D GRE sequence was performed with the patient in the prone and supine position, each acquired during one breathhold period. After division of the colon into five segments, interactive data analysis was carried out using three-dimensional post-processing, including a virtual intraluminal view. The results of CC served as a reference standard. In all patients MRC was performed successfully and no complications occurred. Image quality was diagnostic in 92% (574/620 colonic segments). On a per-patient basis, the results of MRC were as follows: sensitivity 84% (95% CI 71.7-92.3%), specificity 97% (95% CI 89.0-99.6%). Five flat adenomas and 6/16 small polyps (< or =5 mm) were not identified by MRC. MRC offers high sensitivity and excellent specificity rates in patients with clinical indications for CC. Improved MRC techniques are needed to detect small polyps and flat adenomas.

Endoscopic submucosal dissection (ESD) of early neoplastic gastric lesions using a new double-channel endoscope (the "R-scope")

BACKGROUND AND STUDY AIM

Endoscopic submucosal dissection (ESD) allows en bloc resection of lesions > 2 cm in diameter. However the procedure is difficult because of limited visualization of the cutting area. The aim of this study was to evaluate a new endoscope (the "R-scope") for ESD; this provides a second flexible section for improved positioning capability and two instrumentation channels for vertical lifting of the targeted mucosal area and horizontal cutting of the submucosa.

METHODS

The R-scope was tested first for ESD of 17 predetermined gastric areas in eight anesthetized pigs. Clinical experience was then prospectively obtained in 10 patients with early gastric neoplasia. In both instances, dye-stained saline solution was used for repeated submucosal injection. Various types of knives were available for circumferential cutting of the mucosa to isolate the targeted lesion. The specimen was then lifted and the submucosal layer was dissected with the appropriate type of knife to achieve en bloc resection.

RESULTS

ESD succeeded in 14/17 animal cases (82 %), remained incomplete in two cases and failed in one because of an intractable perforation; a further two small perforations were clipped. In 10 patients (with nine early carcinomas and one adenoma, with a median diameter of 22 mm), lesions were completely resected in six cases. Surgery was necessary in two patients due to early and delayed perforation. Three other patients with small amounts of free air were conservatively managed but elective surgery was performed in two of these patients because of incomplete resection or deep submucosal tumor infiltration.

CONCLUSIONS

The R-scope facilitated ESD of large gastric areas in live animal testing and in a small series of patients However the procedure is technically demanding and time-consuming. It was also associated with a high risk of perforation; this may be related to an insufficient volume of solution being injected submucosally, excessively forceful lifting of the specimen, or the short learning period.

A prospective multicenter clinical and endoscopic follow-up study of patients with gastroesophageal reflux disease

BACKGROUND

Despite its high prevalence, data on the course of gastroesophageal reflux disease (GERD) are still sparse. There is also an ongoing debate on the natural history of its various manifestations, i.e., non-erosive reflux disease (NERD) vs. erosive reflux disease (ERD) vs. Barrett's esophagus (BE).

PATIENTS AND METHODS

This study was conducted within the framework of a prospective multicenter study on the course and prevalence of intestinal metaplasia at the gastroesophageal junction. 1014 dyspeptic patients were screened by the means of upper GI endoscopy. Clinical data were recorded by the use of a questionnaire. At least 15 months after the initial examination, all patients were invited for follow-up (FU) examination. Patients were analyzed separately with respect to their clinical and endoscopic findings. For the latter, only patients without any treatment with proton-pump-inhibitors (PPI) prior to initial and follow-up examinations were included. Patients were categorized as GERD positive if typical symptoms were present and/or proton pump inhibitors were used.

RESULTS

Sufficient clinical and/or endoscopic data were available in 590 GERD patients with heartburn at least once a week. Follow-up data could be obtained in 320 patients (clinical FU: n = 304; endoscopic FU: n = 52) after a mean follow-up period of 35 months (18-48 months). 96 of 144 previously asymptomatic patients (67%) remained asymptomatic at follow-up, the rest (n = 48) were symptomatic. 143 of 304 previously symptomatic patients (47%) were symptom-free at follow-up, and only 161 patients (53%) remained symptomatic or had concomitant therapy with proton-pump-inhibitors (PPI). For follow-up endoscopy in patients off PPI (n = 52), ERD was no longer confirmed in 7/12 ERD patients (58%), whereas progress to ERD was found in 3/34 patients (9%) in the NERD group. BE was newly diagnosed in two NERD patients but could no longer be detected in 2 of 6 patients with an initial diagnosis of BE.

CONCLUSIONS

With respect to its clinical as well as its endoscopic manifestations, gastroesophageal reflux disease does not appear to be very stable over time. However, in most cases this is due to regression rather than progression of the disease.

The Aer-O-Scope: proof of the concept of a pneumatic, skill-independent, self-propelling, self-navigating colonoscope in a pig model

BACKGROUND AND STUDY AIMS

Considerable training is needed to enable endoscopists to use the currently available commercial colonoscopes and sigmoidoscopes effectively and safely. The aim of this study was to evaluate the safety and efficacy of the propulsion mechanism incorporated into the Aer-O-Scope (GI View Ltd., Ramat Gan, Israel)--a novel self-propelled, self-navigating colonic endoscope for diagnostic purposes.

MATERIALS AND METHODS

Twenty young female pigs underwent complete bowel preparation followed by a sedated examination using the new device. Ten pigs underwent two consecutive procedures, with a wash-out period of 7 days between each procedure. The total number of procedures was 30. Two prototypes of the Aer-O-Scope, with different cable lengths and vehicle balloon sizes (n = 20 and n = 10 for prototypes I and II, respectively) were used. Each examination was followed by a standard colonoscopy for safety evaluation. The insertion length of the Aer-O-Scope was determined by fluoroscopy images.

RESULTS

The colon was adequately clean in 25 procedures. Maximum insertion was achieved in 21 procedures (84%)--80% with prototype I (n = 15) and 90% with prototype II (n = 10). The time to maximum insertion averaged 8.9 +/- 4.4 min (10 +/- 4.6 and 6.6 +/- 2.9 min for prototypes I and II; P < 0.05), and the withdrawal time averaged 3.4 +/- 2.1 and 4.2 +/- 3.4 min, respectively. The driving pressures for prototypes I and II averaged 46.3 and 34.5 mbar, respectively. The follow-up conventional colonoscopy identified no mucosal tears or perforations. Minor mucosal petechiae were noted in 43% of the cases. No adverse events were noted up to 7 days after the procedure.

CONCLUSIONS

The propulsion mechanism used in this novel self-propelled, self-navigating colonoscope was effective and safe in pigs.

Training in GI endoscopy: can we objectively predict the performance of trainees? A prospective correlation study

BACKGROUND

No objective criteria have hitherto been available for assessing the individual talents and skills of trainees involved in GI endoscopy. The aim of our study was to compare the correlation of various psychological, psychomotor and cognitive tests (psy-tests) and of the subjective assessment of the trainer (expert assessment) at the beginning of the training with the objective performance of the trainees at the end of a one-week training period in upper GI endoscopy.

METHODS

In a prospective study including 12 endoscopic centers, a total of 58 participants without any prior endoscopic experience were analyzed. During a practical training week in each center with the "Erlangen Endo-Trainer," an assessment using a "score card" protocol was used as reference method. Prior to the start of the training, various psy-tests (personality test, vigilance endurance test, test of spatial thinking and two tests of sensorimotor coordination) as well as assessment of the trainer were obtained. These parameters were compared with a blinded analysis of the performance at the end of the training.

RESULTS

There was significant overall improvement during the training course. Multiple logistic regression analysis revealed that testing sensorimotoric coordination was significantly associated with defined improvement margins (odds ratio 11.46, p = 0.035). An expert's judgment on the prognosis correlated also significantly with the trainee's improvement (OR = 41.46; p = 0.018). Self-assessments were not significantly associated with performance or progress.

CONCLUSIONS

Sensorimotoric tests may provide a reliable prediction of the trainee's learning progress. In contrast to self-assessment, the judgement of an experienced endoscopist provides the best guidance for the young candidate endoscopists prior to the start of his/her endoscopic training program.

The Munich Polypectomy Study (MUPS): prospective analysis of complications and risk factors in 4000 colonic snare polypectomies

BACKGROUND AND STUDY AIMS

Screening colonoscopy with polypectomy has been shown to reduce the morbidity and mortality associated with colorectal cancer. However, there is a lack of large and systematic prospective studies of the complications of polypectomy.

PATIENTS AND METHODS

Data on all snare polypectomies performed in 13 institutions (six hospitals and seven gastroenterology offices) were recorded prospectively during a 20-month period, including data on a 30-day follow-up period. The primary end points of the study were polypectomy complications, which were classed as "major" or "minor". Risk factors for complications were analyzed for both patient characteristics and polyp parameters.

RESULTS

A total of 3976 snare polypectomies in 2257 patients (mean age 64.5 years) were included in the study. The mean polyp size was 1.1 cm, and 72% were sessile. Complications occurred in 9.7% of patients (6.1% of polyps); 75% of these complications were minor; and the mortality rate was zero. Multivariate regression analysis revealed polyp size as the main risk factor, both for complications overall (odds ratio 6.56, 95%CI 4.45-9.67) and for major complications (odds ratio 31.01, 95%CI 7.53-128.1). Right-sided polyp location was a significant risk factor for major complications (odds ratio 2.40, 95%CI 1.34-4.28). Setting a cut-off value of 3% as an acceptable rate for major complications, polyps larger than 1 cm in the right colon or 2 cm in the left colon, and multiple polyps carried an increased risk.

CONCLUSIONS

Colonoscopic polypectomy is associated with a 10% rate of complications, but three-quarters of these are of minor clinical significance. More than 90% of the complications can be managed conservatively if adequate endoscopic expertise is available. Guidelines for intensified follow-up after polypectomy should be based on the size, location, and number of a patient's polyps.

[Endoscopic therapy of acute and chronic pancreatitis]

Endoscopic therapy is valuable for both acute and chronic pancreatitis. Early endoscopic papillotomy appears, in the case of a severe course of acute biliary pancreatitis, to be advantageous. Endoscopic drainage can be considered in cases of acute fluid retention and necrosis as well as subacute, non-healing pancreatitis or cyst development. By acute chronic pancreatitis with strictures or bile duct stones, papillotomy, dilation and stent insertion can lead to an improvement in pain symptoms. An improvement in endo- or exocrine function, however, is not expected. Studies on the endoscopic therapy of pancreatitis are still very limited, and recommendations can usually only be made based on retrospective case series.

Long-term failure of endoscopic suturing in the treatment of gastroesophageal reflux: a prospective follow-up study

BACKGROUND AND STUDY AIMS

Several endoscopic antireflux therapies have been marketed, but long-term data on their objective and clinical efficacy are sparse. This report presents prospective 1-year follow-up results, including technical, clinical, and functional success rates, for the first of these treatments to be developed, endoscopic gastroplication (EGP).

PATIENTS AND METHODS

A total of 43 EGP procedures were carried out in 38 patients with gastroesophageal reflux disease (GERD). Two or three EndoCinch gastroplications were constructed at the level of the gastric cardia in each patient; five patients were treated twice within 6 - 12 months. Each endoscopic suture joined two gastric folds to each other as a double fold, known as a "gastroplication", in order to narrow the esophagogastric junction. Postprocedure data after 2 months and after 1 year were compared with preoperative data, focusing on symptoms, medication requirements, endoscopic findings, and pH-metry results.

RESULTS

In contrast to the findings at 2 months (which showed that 72 % of the sutures were present and that there was a reduction in the percentage of time when the esophageal pH was < 4 from 15.4 % to 8.7 %), the results 1 year after EGP were considered to indicate failure of the treatment in all 38 patients because none of them still had all of the initially placed gastroplications in situ (90 % of gastroplications were lost). The percentage of patients who did not require proton pump inhibitor medication decreased from 52 % at 2 months to only 20 % at 1 year and even more patients had evidence of reflux esophagitis at 1 year (56 %) than had initially demonstrated signs of this (41 %).

CONCLUSIONS

EGP has some short-term beneficial effects on clinical symptoms and pH-metry. However, mainly due to the loss of the endoscopically placed sutures, these effects were not maintained at the 1-year follow-up. EGP cannot therefore be recommended for routine clinical use. Better endoscopic methods need to be developed, and they should be adequately tested before being marketed.