Randomised controlled trial of paediatric magnetic positioning device assisted colonoscopy: a pilot and feasibility study

Colonoscope "Looping" During Ileo-Colonoscopy in Children is Significantly Different to that Observed in Adult Practice

OBJECTIVES

Ileo-colonoscopy (IC) can be technically challenging because of unpredictable colonoscope loop formation. Aims of this study were to assess the risk of loop formation and to attempt to understand which factors were likely to predispose to which subtype of loop.

METHODS

Prospective study conducted on children referred for an IC at Sheffield Children's Hospital. Presence and type of loop was objectively assessed using the magnetic endoscope imaging tool.

RESULTS

Three hundred procedures were prospectively evaluated. Only 9% of paediatric ICs were loop-free. Alpha loops were the most common loop in children older than 5, whereas reverse alpha loops and a wider variety of complex and repetitive loops were observed in younger patients. Once a specific type of loop has formed, the risk of re-looping in a different way or in a different position of the colon is reduced. Left lateral starting position was found to increase the risk of reverse alpha loops and re-looping. Challenging loops, such as reverse alpha, were more frequent in males. Higher body mass index (BMI) was associated with an increased risk of alpha and deep transverse loops formation, while lower BMI with a higher incidence of reverse alpha and N loop. Loop formation did not prevent 100% ileal intubation.

CONCLUSIONS

This study represents the first attempt to describe loop formation according to patient characteristics in a large paediatric series. Further studies are needed in order to establish if these findings could be helpful in simplifying the execution of IC procedures in children and facilitate the learning curve during endoscopy training programs.

Magnetic endoscopic imaging as a rational investment for specific colonoscopies: a systematic review and meta-analysis

BACKGROUND

Magnetic endoscopic imaging (MEI) was regarded as an adjuvant device to improve procedural efficacy and patients' comfort during colonoscopy.

METHODS

Several electronic databases were searched to identify eligible studies. Based on the heterogeneity of included studies, random-effects or fixed-effects models were used to calculate pooled risk ratios (RR), risk difference (RD) or mean difference (MD) along with 95% confidence intervals (CIs).

RESULTS

Twenty-one randomized controlled trials (RCTs) were selected for meta-analysis, with a total of 7,060 patients. Although there is a slightly lower risk of cecal intubation failure with the adjuvant of MEI (RD 3%; P < 0.00001) compared to the control group, the updated studies show no significant benefits. Similarly, the cecal intubation time, pain scores, and loop formation with the adjuvant of MEI did not show any advantages. However, considerable significant benefits were found in the subgroup of technically difficult colonoscopy and inexperienced colonoscopists. Moreover, MEI was associated with lower loop intubation time, lower abdominal compression times, and better lesion localization.

CONCLUSION

The clinical benefits of MEI could be exaggerated. However, MEI has considerable advantages in technically difficult colonoscopies, the assistance for inexperienced colonoscopists, loop resolving, and lesion localization.

When and why a colonoscopist should discontinue colonoscopy by himself?

AIM: To investigate when and why a colonoscopist should discontinue incomplete colonoscopy by himself.

METHODS: In this cross-sectional study, 517 difficult colonoscope insertions (Grade C, Kudo’s difficulty classification) screened from 37800 colonoscopy insertions were collected from April 2004 to June 2014 by three 4^th-level (Kudo’s classification) colonoscopists. The following common factors for the incomplete insertion were excluded: structural obstruction of the colon or rectum, insufficient colon cleansing, discontinuation due to patient’s discomfort or pain, severe colon disease with a perforation risk (e.g., severe ischemic colonopathy). All the excluded patients were re-scheduled if permission was obtained from the patients whose intubation had failed. If the repeat intubations were still a failure because of the difficult operative techniques, those patients were also included in this study. The patient’s age, sex, anesthesia and colonoscope type were recorded before colonoscopy. During the colonoscopic examination, the influencing factors of fixation, tortuosity, laxity and redundancy of the colon were assessed, and the insertion time (> 10 min or ≤ 10 min) were registered. The insertion time was analyzed by t-test, and other factors were analyzed by univariate and multivariate logistic regression.

RESULTS: Three hundred and twenty-two (62.3%) of the 517 insertions were complete in the colonoscope insertion into the ileocecum, but 195 (37.7%) failed in the insertion. Fixation, tortuosity, laxity or redundancy occurred during the colonoscopic examination. Multivariate logistic regression analysis revealed that fixation (OR = 0.06, 95%CI: 0.03-0.16, P < 0.001) and tortuosity (OR = 0.04, 95%CI: 0.02-0.08, P < 0.001) were significantly related to the insertion into the ileocecum in the left hemicolon; multivariate logistic regression analysis also revealed that fixation (OR = 0.16, 95%CI: 0.06-0.39, P < 0.001), tortuosity (OR 0.23, 95%CI: 0.13-0.43, P < 0.001), redundancy (OR = 0.12, 95%CI: 0.05-0.26, P < 0.001) and sex (OR = 0.35, 95%CI: 0.20-0.63, P < 0.001) were significantly related to the insertion into the ileocecum in the right hemicolon. Prolonged insertion time (> 10 min) was an unfavorable factor for the insertion into the ileocecum.

CONCLUSION: Colonoscopy should be discontinued if freedom of the colonoscope body’s insertion and rotation is completely lost, and the insertion time is prolonged over 30 min.

Magnetic endoscopic imaging vs standard colonoscopy: Meta-analysis of randomized controlled trials

AIM: To assess the theoretical advantages of magnetic endoscope imaging (MEI) over standard colonoscopies (SCs) and to compare their efficacies.

METHODS: Electronic databases, including PubMed, EMBASE, the Cochrane library and the Science Citation Index, were searched to retrieve relevant trials. In addition, abstracts from papers presented at professional meetings and the reference lists of retrieved articles were reviewed to identify additional studies. The meta-analyses were performed using RevMan 5.1. A random effect model with the Mantel-Haenszel method was used for pooling dichotomous and continuous data. A sensitivity analysis was performed by excluding the trials with a small number of patients and by excluding the trials performed by inexperienced providers.

RESULTS: Eight randomized controlled trials (RCTs), including 2967 patients, were included in the meta-analysis to compare cecal intubation rates and times, sedation dose, abdominal pain scores and the use of ancillary maneuvers between MEI and SC. The overall OR was 1.92 (95%CI: 1.13-3.27, eight RCTs), as indicated by the cecal intubation rate of MEI compared with SC, but MEI did not have any distinct advantage over SC for cecal intubation time (MD = -0.07, 95%CI: -0.16-0.02; three RCTs). MEI did not generally result in lower pain scores. Outcomes were also analyzed for the two subgroups based on the endoscopists’ experience level to evaluate cecal intubation rates. MEI presented better outcomes for non-experienced colonoscopists than experienced colonoscopists.

CONCLUSION: The real-time magnetic imaging system is of benefit in training and educating inexperienced endoscopists and improves the cecal intubation rate for experienced and inexperienced endoscopists.

Evaluation of magnetic scope navigation in screening endoscopic examination of colorectal cancer

Background

Colorectal cancer is the most common cancer in Europe. Early diagnosis and treatment gives the patient a chance for complete recovery. Screening colonoscopies in the symptom-free patients are currently performed on a wide scale. The examinations are performed under local anesthesia which does not eliminate all discomfort and pain related to the examination. The aim of this study was to evaluate magnetic scope navigation in screening endoscopic examinations performed to detect early-stage colorectal cancer.

Methods

The study group consisted of 200 patients, aged 40–65 years, who were free from colon cancer symptoms. All patients underwent complete colonoscopy under local anesthesia. The equipment could be fitted with the scope that allows three-dimensional observation of instrument localization in the bowel. The examination was performed by three experienced endoscopists, each of whom performed over 5,000 colonoscopies. The patients were randomized to two groups: those whose equipment did not have 3D navigation (group I) and those whose equipment did have 3D navigation (group II). Each group consisted of 100 cases matched by gender, age, and BMI. The authors compared the duration of introducing instrument to cecum, the pulse rate before the examination and at the time the instrument reached the cecum, and subjective pain evaluation by the patient on the visual analog scale.

Results

Group I consisted of 54 women and 46 men with a mean age of 54.6 years and mean BMI of 27.8 kg/m², and group II had 58 women and 42 men, mean age of 55.1 years and mean BMI of 26.4 kg/m². The average time it took for the instrument to reach the cecum was 216s in group I and 181s in group II (P < 0.05). Pain measured on the 10-point VAS scale was 2.44 in group I and 1.85 in group II (P < 0.05). The results showed a significantly shorter time for the instrument to reach the cecum in group II and significantly lower pain intensity during the examination was reported by the group II patients. No significant differences were found in the pulse measurements between the groups (P = 0.5).

Conclusions

3D navigation during colonoscopy decreases the time for the instrument to reach the cecum and lowers pain intensity subjectively reported by the patients. The use of 3D and the possibility to observe instrument localization and maneuvers brings more comfort to the patients.