The detection of oesophageal varices using a novel, disposable, probe-based transnasal endoscope: a prospective diagnostic pilot study

Evaluation of a novel disposable endoscope for retroflexed endoscopic rubber band ligation of internal hemorrhoids: a randomized pilot study

PURPOSE

Retroflexed endoscopic rubber band ligation (ERBL) for treating Grade II and III internal hemorrhoids using disposable endoscopes has not been previously assessed. We therefore compared the safety and effectiveness of ERBL for internal hemorrhoids using novel disposable endoscopes versus traditional reusable endoscopes.

METHODS

This prospective randomized controlled trial involved 42 patients who underwent ERBL for Grade II and III internal hemorrhoids using either a disposable endoscope (n = 21) or a reusable endoscope (n = 21). Safety was assessed by the incidence of equipment failure, device-related adverse events, and in-procedure stability of vital signs. Effectiveness was assessed by the postoperative therapeutic effect, feasibility of retroflexed ERBL, and incidence of complications.

RESULTS

In terms of safety, no life-threatening events, equipment failure, or device-related adverse effects occurred during the procedures in either group. The rate of diastolic blood pressure stability was significantly different between the two groups (P = .049), but the rates of systolic blood pressure and heart rate stability were similar. In terms of effectiveness, the therapeutic effects on postoperative Day 30 were similar in both groups. Image clarity and endoscopic flexibility in the disposable endoscope group were mildly inferior to those in the reusable endoscope group, but without statistical significance. Matching between the endoscope and ligating device was 100% in both groups. The incidence of complications on postoperative Days 1 and 10 was not significantly different between the two groups.

CONCLUSION

Compared with reusable endoscopes, disposable endoscopes are equally safe, feasible, and reliable in ERBL for internal hemorrhoids.

Small varices in chronic liver diseases

PURPOSE OF REVIEW

Gastroesophageal varices are common complications of chronic liver diseases (CLDs) and portal hypertension. Small varices have the risk of progressing to larger varices, causing bleeding or even death. Thus, early detection and appropriate management of small varices are necessary. The purpose of this review is to summarize the advance in the recent 5years about diagnosing and managing the small varices in CLDs.

RECENT FINDINGS

The diagnosing methods of small varices in recent studies include improved endoscopic examinations, such as capsule endoscopy, and many noninvasive methods, including blood tests, ultrasound, computed tomography and magnetic resonance. For the management of small varices, though it is controversial, prevention using nonselective beta-blockers is still an essential part.

SUMMARY

In this review, we summarize the classification of varices, the invasive and noninvasive diagnostic methods, their performances, and the emerging progression in the management of small varices in the recent 5 years. We hope that this review provides relevant information to understand better and appropriately manage small varices.

Acceptability to patients of screening disposable transnasal endoscopy: qualitative interview analysis

OBJECTIVES

Screening in selected high risk populations for Barrett's oesophagus (BO) and oesophageal varices (OVs) has been proposed, but there are obstacles with conventional oesophagogastroduodenoscopy (C-OGD), including patient acceptability. Portable and disposable office-based transnasal endoscopy (TNE) is a feasible and accurate alternative to C-OGD that may have use in primary and secondary care. This article outlines a qualitative analysis of patient experiences of TNE and C-OGD in order to gain an insight into an acceptable delivery of an endoscopic screening service.

DESIGN

Purposeful sampling identified 23 participants who then underwent semi-structured interviews to determine their experiences of both procedures. Thematic analysis was conducted to derive meaning from their lived experiences.

SETTING

A secondary care endoscopy unit, clinic room and interview room.

PARTICIPANTS

Patients referred for BO or OV surveillance and for endoscopy to investigate dyspepsia underwent unsedated TNE using the EG Scan II device followed by C-OGD with or without sedation (patient choice), as part of a clinical trial.

RESULTS

The themes that arose from our analysis were: inclusivity in one's own healthcare, comfort level and convenience, validity of the procedure and application to a screening population and a sense of altruism and reciprocity. Positive aspects of TNE included participant empowerment, reduced discomfort and avoidance of conscious sedation. Participants felt that if TNE screening was of proven efficacy it would be welcomed, though views on use in a community setting were mixed.

CONCLUSIONS

Most patients preferred TNE to unsedated C-OGD and the reasons they gave featured strongly in the emerging themes. Preferences between TNE and sedated C-OGD were more subtle, with equivalent comfort scores but merits and drawbacks of both being discussed. This information identifies opportunities and challenges in establishing an endoscopic screening service. Trial registration number ISRCTNregistry identifier: 70595405; Pre-results.

An Operable, Portable, and Disposable Ultrathin Endoscope for Evaluation of the Upper Gastrointestinal Tract

BACKGROUND AND AIMS

A prototype of a disposable endoscope (DE) with easy viewing of the esophagus has been developed. The aim of this study was to develop a new version of DE with improved functionality and to assess the feasibility of DE as a screening tool for upper gastrointestinal diseases compared with conventional endoscopes.

METHODS

Diagnostic accuracy and maneuverability of DE were evaluated by comparing endoscopy using DE with conventional endoscopy. Different examiners performed DE endoscopy and conventional endoscopy in a randomized order, blinded to the results. Examiners were asked to respond to a questionnaire about ease of handling and observation using DE in preformed result sheets. Tolerability of DE was also evaluated. Non-sedated participants were asked to respond to a questionnaire about the convenience and satisfaction with DE endoscopy on a nine-point Likert scale.

RESULTS

The overall ease of insertion and handling of DE was excellent. The new device enabled observation and evaluation of the entire esophagus with a good agreement between DE endoscopy and conventional endoscopy in terms of endoscopic diagnosis (Kappa value; hiatal hernia; 0.910, reflux esophagitis; 0.949, Barrett's esophagus, 1.000). Participants suggested that they were more comfortable with DE endoscopy than with conventional endoscopy with a lower symptom score (p = 0.030).

CONCLUSION

The new DE enabled easy observation of the entire esophagus owing to its improved maneuverability, and its diagnostic ability of esophageal diseases was comparable to that of conventional endoscopes. Non-sedated esophagoscopy with this disposable device potentially has widespread applications in outpatient clinics and areas without endoscopic facilities.

Systematic review with meta-analysis: ultra-thin gastroscopy compared to conventional gastroscopy for the diagnosis of oesophageal varices in people with cirrhosis

BACKGROUND

Haemorrhage from ruptured oesophageal varices is a common cause of death in people with cirrhosis. Guidelines recommend screening for varices at time of cirrhosis diagnosis and throughout the course of the disease. Conventional gastroscopy is the criterion standard for variceal screening; however, is invasive, costly, and carries risks related to use of sedation. Ultra-thin gastroscopy (using endoscopes with a shaft diameter ≤6 mm) has been proposed as an alternative method of variceal screening that mitigates these risks.

AIM

To determine the diagnostic accuracy of ultra-thin gastroscopy compared to conventional gastroscopy for the diagnosis of varices in people with cirrhosis.

METHODS

MEDLINE, EMBASE and Cochrane library databases were searched for studies that evaluated the accuracy of ultra-thin gastroscopy compared to conventional gastroscopy in the diagnosis of oesophageal varices.

RESULTS

Ten studies, 7 in known cirrhosis, with 752 participants were included in this systematic review. The overall prevalence of oesophageal varices was 42%. On bivariate modelling, pooled estimates of sensitivity and specificity were 98% (95% CI 93%-99%) and 96% (95% CI 91%-99%) respectively. The positive and negative likelihood ratios were 28 (95% CI 10.7-73.2) and 0.02 (95% CI 0.01-0.72) respectively. Kappa coefficient for inter-observer agreement for any varices ranged from 0.45 to 0.90. No serious adverse events related to ultra-thin gastroscopy were reported.

CONCLUSIONS

Ultra-thin gastroscopy is accurate in the diagnosis of oesophageal varices, safe and well tolerated. It is a valid alternative to conventional gastroscopy for the screening and surveillance of varices in people with cirrhosis.

Reliability and safety of transnasal compared to conventional endoscopy for detecting oesophageal varices in cirrhotic patients

BACKGROUND & AIMS

Unsedated transnasal endoscopy may be used for detecting oesophageal varices. However, few studies evaluated feasibility and accuracy of this technique. We aimed to evaluate accuracy, interobserver agreement and safety of the transnasal ultrathin compared to conventional endoscopy in patients with cirrhosis.

METHODS

This cross-sectional study included consecutive patients referred for screening or surveillance of oesophageal varices. Patients underwent unsedated transnasal and sedated conventional endoscopies at the same day, which were recorded in a digital video file and randomly analysed by two double-blinded endoscopists. High-risk varices were defined by the presence of large calibre or red wale marks. Accuracy, interobserver agreement and safety of transnasal were compared to conventional endoscopy.

RESULTS

One hundred and thirty-three cirrhotic patients (48% male, aged of 60 ± 5, 34% Child-Pugh B/C and 71% of cases for variceal screening) were included in the study. The prevalence of oesophageal varices and high-risk oesophageal varices were 59% (n = 79) and 29% (n = 39) respectively. For the presence of oesophageal varices, transnasal GIE yielded sensitivity of 94% [95% Confidence Interval, CI 88-99], specificity of 89% [81-97] as well as positive and negative predictive value of 93% and 91% respectively. A satisfactory interobserver agreement was observed for the presence of oesophageal varices (κ = 0.89) and high-risk varices (κ = 0.65). No serious adverse events were recorded; transnasal GIE was safe and significantly associated with lower rates of hypoxaemia (P < .0001) and hypotension (P < .0001) compared to conventional endoscopy.

CONCLUSIONS

Unsedated transnasal endoscopy was safe and had an excellent accuracy and high interobserver agreement for detecting oesophageal varices and for identifying high-risk varices in cirrhotic patients.

The noninvasive diagnosis of esophageal varices and its application in clinical practice

Here, we review recent improvements made to different noninvasive tests used for the diagnosis of esophageal varices (EV) in the light of the recent Baveno VI recommendation and with an emphasis on clinical application. Like for fibrosis tests, these noninvasive EV tests can be classified as direct markers when they provide a visualization of EV (including all imaging procedures like endoscopy or radiology) and as indirect markers when they do not (blood markers or elastometry). Clinical descriptors expressed as percentages, especially the spared endoscopy rate and the missed high-risk esophageal varices (HREV) rate, are more eloquent in this setting than classical statistical descriptors like accuracy. Single biomarkers are insufficient, generally due to a missed HREV rate exceeding the acceptable limit of 5% indicated in the Baveno VI consensus. Thus, biomarker combinations are currently garnering the most interest. The Baveno VI recommendation states that in alcoholic and viral cirrhoses, screening endoscopy can be safely set aside for patients with liver stiffness<20kPa and platelets>150G/L. The Baveno rule's mean missed HREV rate is<5% but its spared endoscopy rate is<20%. New combinations or stepwise algorithms show promise but must be validated. Going forward, the Baveno rule provides a simple noninvasive method to rule out HREV in clinical practice but the need for further research continues. The noninvasive diagnosis of HREV will be significantly improved by new, simple and affordable combinations.

Large oesophageal varice screening by a sequential algorithm using a cirrhosis blood test and optionally capsule endoscopy

BACKGROUND & AIMS

Large oesophageal varice (LEV) screening is recommended in cirrhosis. We performed a prospective study to improve non-invasive LEV screening.

DESIGN

287 patients with cirrhosis had upper gastrointestinal endoscopy (LEV reference), oesophageal capsule endoscopy (ECE), liver elastography and blood marker analyses. CirrhoMeter (cirrhosis blood test), the most accurate non-invasive LEV test, was segmented for cirrhosis (reference comparator) or LEV. VariScreen, a sequential and partially minimally invasive diagnostic algorithm, was developed by multivariate analysis. It uses CirrhoMeter first, then ECE if CirrhoMeter cannot rule LEV out or in, and finally endoscopy if CirrhoMeter+ECE combination remains uninformative.

RESULTS

Diagnostic effectiveness rates for LEV were: cirrhosis-segmented CirrhoMeter: 14.6%, LEV-segmented CirrhoMeter: 34.6%, ECE: 60.6% and VariScreen: 66.4% (P ≤ .001 for overall or pair comparison). The respective missed LEV rates were: 2.8%, 5.6%, 8.3% and 5.6% (P = .789). Spared endoscopy rates were, respectively: 15.6%, 36.0%, 70.6% and 69%, (P < .001 for overall or paired comparison except ECE vs VariScreen: P = .743). VariScreen spared 38% of ECE and reduced missed LEV by 87% compared to classical ECE performed in all patients. Excepting cirrhosis-segmented CirrhoMeter, these spared endoscopy rates were significantly higher than that of the Baveno VI recommendation (using platelets and Fibroscan): 18.4% (P < .001). Ascites and Child-Pugh class independently predicted endoscopy sparing by VariScreen: from 86.0% in compensated Child Pugh class A to 24.1% in Child-Pugh class C with ascites.

CONCLUSION

VariScreen algorithm significantly reduced the missed LEV rate with ECE by 87%, ECE use by 38% and endoscopy requirement by 69%, and even 86% in compensated cirrhosis.