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Córdova H, Barreiro-Alonso E, Castillo-Regalado E, Cubiella J, Delgado-Guillena P, Díez Redondo P, Galdín M, García-Rodríguez A, Hernández L, Huerta A, Jover R, Núñez H, Rodríguez-D'Jesús A, Seoane A, Surís G, Tejedor-Tejada J, Jiménez Sánchez J, Martín F, Moreira L, Carballal S, Rivero L, Da Fieno A, Casanova G, Luzko Scheid I, Llach J, Fernández-Esparrach G. Applicability of the Barcelona scale to assess the quality of cleanliness of mucosa at esophagogastroduodenoscopy. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:246-252. [PMID: 37236304 DOI: 10.1016/j.gastrohep.2023.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/11/2023] [Accepted: 05/18/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND AND OBJECTIVES There are few scales with prospective validation for the assessment of the upper gastrointestinal mucosal cleanliness during an esophagogastroduodenoscopy (EGD). The aim of this study was to develop a valid and reproducible cleanliness scale for use during an EGD. METHODS We developed a cleanliness scale (Barcelona scale) with a score (0-2 points) of five segments of the upper gastrointestinal tract with thorough cleaning techniques (esophagus, fundus, body, antrum, and duodenum). First, 125 photos (25 of each area) were assessed, and a score was assigned to each image by consensus among 7 experts endoscopists. Subsequently, 100 of the 125 images were selected and the inter- and intra-observer variability of 15 previously trained endoscopists was evaluated using the same images at two different times. RESULTS In total, 1500 assessments were performed. In 1336/1500 observations (89%) there was agreement with the consensus score, with a mean kappa value of 0.83 (0.45-0.96). In the second evaluation, in 1330/1500 observations (89%) there was agreement with the consensus score, with a mean kappa value of 0.82 (0.45-0.93). The intra-observer variability was 0.89 (0.76-0.99). CONCLUSIONS The Barcelona cleanliness scale is a valid measure and reproducible with minimal training. Its application in clinical practice is a significant step to standardize the quality of the EGD.
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Affiliation(s)
- Henry Córdova
- Endoscopy Unit, Gastroenterology Department, Hospital Clínic of Barcelona, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Eva Barreiro-Alonso
- Department of Gastroenterology, Hospital Universitario Central de Asturias and Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Edgar Castillo-Regalado
- Endoscopy Unit, Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Joaquín Cubiella
- Department of Gastroenterology, Hospital Universitario de Ourense. Research Group in Gastrointestinal Oncology-Ourense. CIBERehd, Ourense, Spain
| | | | | | | | - Ana García-Rodríguez
- Servicio de Digestivo, Unidad de Endoscopia, Hospital de Viladecans, Barcelona, Spain
| | | | - Alain Huerta
- Hospital Universitario de Galdakao, Biocruces Bizkaia, Departamento Medicina UPV-EHU Leioa, Spain
| | - Rodrigo Jover
- Servicio de Medicina Digestiva, Hospital General Universitario Dr. Balmis, Instituto de Investigación Sanitaria ISABIAL, Universidad Miguel Hernández, Alicante, Spain
| | - Henar Núñez
- Hospital Universitario Río Hortega, Valladolid, Spain
| | | | - Agustín Seoane
- Digestive Department, Endoscopy Unit, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Gerard Surís
- Servicio de Digestivo, Unidad de Endoscopia, Hospital de Viladecans, Barcelona, Spain
| | | | | | | | - Leticia Moreira
- Endoscopy Unit, Gastroenterology Department, Hospital Clínic of Barcelona, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Sabela Carballal
- Endoscopy Unit, Gastroenterology Department, Hospital Clínic of Barcelona, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Liseth Rivero
- Endoscopy Unit, Gastroenterology Department, Hospital Clínic of Barcelona, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Angella Da Fieno
- Endoscopy Unit, Gastroenterology Department, Hospital Clínic of Barcelona, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Gherzon Casanova
- Endoscopy Unit, Gastroenterology Department, Hospital Clínic of Barcelona, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Irina Luzko Scheid
- Endoscopy Unit, Gastroenterology Department, Hospital Clínic of Barcelona, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Joan Llach
- Endoscopy Unit, Gastroenterology Department, Hospital Clínic of Barcelona, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Gloria Fernández-Esparrach
- Endoscopy Unit, Gastroenterology Department, Hospital Clínic of Barcelona, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain.
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Stepan M, Fojtík P, Psar R, Hanousek M, Sabol M, Zapletalova J, Falt P. Administration of maximum dose of mucolytic solution before upper endoscopy - a double-blind, randomized trial. Eur J Gastroenterol Hepatol 2023; 35:635-640. [PMID: 37115977 PMCID: PMC10144268 DOI: 10.1097/meg.0000000000002559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/11/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVE The aim of the study was to demonstrate that an administration of mucolytic solution with a maximum dose of simethicone and n -acetylcysteine before upper endoscopy improves mucosal visibility compared to a group without administration of mucolytic solution or water. METHODS This study was a double-blind, randomized controlled trial. Patients were randomized into four groups, with the administration of 100 ml of water + 600 mg n -acetylcysteine + 400 mg simethicone, 100 ml of water + 400 mg n -acetylcysteine + 20 mg simethicone, 100 ml of water, and without any water or mucolytic solution. During the examination, a total of 10 images were taken in the defined areas. The overall visibility score was given by the sum of the 0-5 scores of the five areas and was assessed by the endoscopist performing the procedure and the blinded endoscopists using static images. RESULTS A total of 129 patients were randomized. The group of patients did not differ in age, sex distribution, and indications significantly. The overall visibility score as assessed by the endoscopist performing the procedure was significantly higher in the group with the maximum dose of mucolytic solution compared to the group without solution or water (18.9 ± 2.9 vs. 16.6 ± 3.3, P = 0.023). This difference was not evident by the blinded evaluation of static photographs. CONCLUSION Administration of mucolytic solution with a maximum dose of n -acetylcysteine and simethicone before upper endoscopy improved mucosal visibility in the upper gastrointestinal tract compared with the group without any preparation while evaluated by performing endoscopist.
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Affiliation(s)
- Michal Stepan
- Digestive Diseases Center, Vítkovice Hospital
- Faculty of Medicine, University of Ostrava, Ostrava
- Faculty of Medicine, Palacky University, Olomouc
| | - Petr Fojtík
- Digestive Diseases Center, Vítkovice Hospital
- Faculty of Medicine, University of Ostrava, Ostrava
| | - Robert Psar
- Department of Radiology, Vítkovice Hospital, Ostrava
- Department of Radiology, Faculty of Medicine and Dentistry, University Hospital Olomouc
| | | | - Marek Sabol
- Digestive Diseases Center, Vítkovice Hospital
| | | | - Premysl Falt
- 2nd Department of Internal Medicine, University Hospital and Faculty of Medicine, Palacky University, Olomouc, Czech Republic
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Namasivayam V, Uedo N. Quality indicators in the endoscopic detection of gastric cancer. DEN OPEN 2023; 3:e221. [PMID: 37051139 PMCID: PMC10083214 DOI: 10.1002/deo2.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 02/10/2023] [Accepted: 02/26/2023] [Indexed: 04/14/2023]
Abstract
Gastroscopy is the reference standard for the diagnosis of gastric cancer, but it is operator-dependent and associated with missed gastric cancer. The proliferation of gastroscopic examinations, increasingly for the screening and detection of subtle premalignant lesions, has motivated scrutiny of quality in gastroscopy. The concept of a high-quality endoscopic examination for the detection of superficial gastric neoplasia has been defined by expert guidelines to improve mucosal visualization, engender a systematic examination process and detect superficial neoplasia. This review discusses the evidence supporting the components of a high-quality diagnostic gastroscopic examination in relation to the detection of gastric cancer, and their potential role as procedural quality indicators to drive a structured improvement in clinically meaningful outcomes.
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Affiliation(s)
| | - Noriya Uedo
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
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Abstract
BACKGROUND : Assessment of mucosal visualization during esophagogastroduodenoscopy (EGD) can be improved with a standardized scoring system. To address this need, we created the Toronto Upper Gastrointestinal Cleaning Score (TUGCS). METHODS : We developed the TUGCS using Delphi methodology, whereby an international group of endoscopy experts iteratively rated their agreement with proposed TUGCS items and anchors on a 5-point Likert scale. After each Delphi round, we analyzed responses and refined the TUGCS using an 80 % agreement threshold for consensus. We used the intraclass correlation coefficient (ICC) to assess inter-rater and test-retest reliability. We assessed internal consistency with Cronbach's alpha and item-total and inter-item correlations with Pearson's correlation coefficient. We compared TUGCS ratings with an independent endoscopist's global rating of mucosal visualization using Spearman's ρ. RESULTS : We achieved consensus with 14 invited participants after three Delphi rounds. Inter-rater reliability was high at 0.79 (95 %CI 0.64-0.88). Test-retest reliability was excellent at 0.83 (95 %CI 0.77-0.87). Cronbach's α was 0.81, item-total correlation range was 0.52-0.70, and inter-item correlation range was 0.38-0.74. There was a positive correlation between TUGCS ratings and a global rating of visualization (r = 0.41, P = 0.002). TUGCS ratings for EGDs with global ratings of excellent were significantly higher than those for EGDs with global ratings of fair (P = 0.01). CONCLUSION : The TUGCS had strong evidence of validity in the clinical setting. The international group of assessors, broad variety of EGD indications, and minimal assessor training improves the potential for dissemination.
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Feng SM, Zhao Y, Xu Q, Li HM, Huang YX, Liu HH, Xu CB. Development and Characterization of A New Dimethicone Nanoemulsion and its Application for Electronic Gastroscopy Examination. Int J Nanomedicine 2020; 15:5405-5416. [PMID: 32801696 PMCID: PMC7401323 DOI: 10.2147/ijn.s251113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/18/2020] [Indexed: 01/01/2023] Open
Abstract
Purpose Although the effective and safe medical defoamers, dimethicone (DM) and simethicone (SM) are widely used in electronic gastroscope examination (EGE), their preparations are presented in the form of suspensions or emulsions, these are untransparent or milk-like in appearance and can easily cause misdiagnosis as a result of an unclear field of vision if the doctor does not master the amount of defoamer or operates incorrectly. At the same time, it is also difficult to wash out the camera and pipeline, due to the large oil droplets of preparations. The purpose of this study was to develop a new clear and transparent oil in water (O/W) DM nanoemulsions (DMNs) and observe the effect of application in EGE. Methods The oil phase was chosen for its antifoaming activity and viscosity. The emulsifier and co-emulsifier were selected according to the solubility of the oil phase in them. The water titration method was used to make the pseudoternary phase diagrams of nanoemulsions and optimize the prescription composition. DM-in-water nanoemulsion was prepared by the low energy method and evaluated for appearance, antifoaming ability, droplet size, and stability. The effect of DMNs utilized in EGEs was also observed. Results The optimal formulation of DMNs contained CRH-40 as an emulsifier, PEG-400 as a co-emulsifier, DM as oil phase with the viscosity of 10 mPa.s, and their proportion was 4.5:4.5:1, respectively. DMNs obtained the average particle size of 67.98 nm with the polydispersity index (PDI) of 0.332, and 57.14% defoaming rate. The result of using an EGE showed that DMNs were superior in comparison to the emulsions with regard to the defoaming effect, visual clarity, and easy cleanup. Conclusion DMNs were found to provide excellent visual clarity to its other preparations. The novel DMNs is a promising substitute for DM emulsions or suspensions in EGEs.
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Affiliation(s)
- Suo-Min Feng
- Shaanxi Key Laboratory of Ischemic Cardiovascular Disease, Xi'an Medical University, Xi'an 710021, People's Republic of China.,School of Pharmacy, Xi'an Medical University, Xi'an 710021, People's Republic of China
| | - Ying Zhao
- School of Life Science and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang 110016, People's Republic of China
| | - Qing Xu
- College of Life Sciences, Northwest University, Xi'an 710069, People's Republic of China
| | - Hui-Min Li
- Public Course Teaching Department, Shangluo Vocational and Technical College, Shangzhou, 726000, People's Republic of China
| | - Yu-Xiu Huang
- Department of English, Xi'an Medical University, Xi'an 710021, People's Republic of China
| | - Huan-Huan Liu
- Shaanxi Key Laboratory of Ischemic Cardiovascular Disease, Xi'an Medical University, Xi'an 710021, People's Republic of China
| | - Cang-Bao Xu
- Shaanxi Key Laboratory of Ischemic Cardiovascular Disease, Xi'an Medical University, Xi'an 710021, People's Republic of China
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Januszewicz W, Kaminski MF. Quality indicators in diagnostic upper gastrointestinal endoscopy. Therap Adv Gastroenterol 2020; 13:1756284820916693. [PMID: 32477426 PMCID: PMC7232050 DOI: 10.1177/1756284820916693] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/06/2020] [Indexed: 02/04/2023] Open
Abstract
Upper gastrointestinal (UGI) endoscopy contributes a major clinical service with consistently growing demand around the world. Its utility corresponds to varying epidemiological issues throughout the globe, with cancer screening and surveillance being of the utmost priority. Despite high accuracy in neoplasia detection, UGI endoscopy remains a highly operator-dependent procedure, characterized by a substantial rate of missed pathology. Despite an overall lack of high-quality performance measures, there is an increased level of awareness about the need for quality control of this procedure, which is reflected in several guidelines and position statements published in recent years. It is widely recognized that quality assessment should go beyond mere technical aspects of the examination, and include both pre- and post-procedural factors. By this means, quality control encompasses the entire patient experience with the health care provider, from appropriate indication and physical assessment, through high-quality endoscopy service, to appropriate follow up and patient satisfaction. This article aims to review the available and emerging quality metrics for UGI endoscopy, taken mostly from Western endoscopy societies, with references to Asian recommendations where appropriate. The paper is limited solely to diagnostic UGI endoscopy and does not include performance measures for therapeutic procedures.
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Affiliation(s)
| | - Michal F. Kaminski
- Department of Gastroenterological Oncology, the
Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology,
Warsaw, Poland,Department of Gastroenterology, Hepatology and
Clinical Oncology, Center of Postgraduate Medical Education, Warsaw,
Poland,Department of Cancer Prevention, the Maria
Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw,
Poland,Institute of Health and Society, University of
Oslo, Oslo, Norway
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Kim SJ, Choi CW. Common Locations of Gastric Cancer: Review of Research from the Endoscopic Submucosal Dissection Era. J Korean Med Sci 2019; 34:e231. [PMID: 31496141 PMCID: PMC6732260 DOI: 10.3346/jkms.2019.34.e231] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 08/02/2019] [Indexed: 12/24/2022] Open
Abstract
Detection of early-stage gastric cancer improves the prognosis of patients. Endoscopic submucosal dissection (ESD) is a curative and stomach-preserving treatment for early gastric cancer (EGC) associated with a low risk of lymph node metastasis. However, several studies have reported missed diagnosis of gastric cancer. Therefore, endoscopists are required to learn accurate diagnostic skills to eliminate endoscopic blind spots. A systematic screening protocol to map the entire stomach without blind spots reduces the risk of missed lesions. Knowledge of the features of EGC or dysplasia is essential to identify suspicious lesion. Information of the common sites of occurrence of EGC can also enable a detailed endoscopic examination to improve detection rates. Previous reports investigating the location of gastric cancers resected by ESD or surgery showed that the antrum and lesser curvature of stomach were predominantly affected. Helicobacter pylori-induced atrophic changes advance from the antrum to the corpus along the lesser curvature, predominantly affecting these areas. Gastric cancers in the antrum and the lower corpus are also commonly missed during screening examination. Therefore, a careful examination of the lower third stomach is warranted to avoid missing synchronous and metachronous gastric lesions. Knowledge of the location of EGC enables accurate endoscopic examination and detection of EGC in early stage.
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Affiliation(s)
- Su Jin Kim
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Cheol Woong Choi
- Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.
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Chiu PWY, Uedo N, Singh R, Gotoda T, Ng EKW, Yao K, Ang TL, Ho SH, Kikuchi D, Yao F, Pittayanon R, Goda K, Lau JYW, Tajiri H, Inoue H. An Asian consensus on standards of diagnostic upper endoscopy for neoplasia. Gut 2019; 68:186-197. [PMID: 30420400 DOI: 10.1136/gutjnl-2018-317111] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 09/25/2018] [Accepted: 10/15/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND This is a consensus developed by a group of expert endoscopists aiming to standardise the preparation, process and endoscopic procedural steps for diagnosis of early upper gastrointestinal (GI) cancers. METHOD The Delphi method was used to develop consensus statements through identification of clinical questions on diagnostic endoscopy. Three consensus meetings were conducted to consolidate the statements and voting. We conducted a systematic literature search on evidence for each statement. The statements were presented in the second consensus meeting and revised according to comments. The final voting was conducted at the third consensus meeting on the level of evidence and agreement. RESULTS Risk stratification should be conducted before endoscopy and high risk endoscopic findings should raise an index of suspicion. The presence of premalignant mucosal changes should be documented and use of sedation is recommended to enhance detection of superficial upper GI neoplasms. The use of antispasmodics and mucolytics enhanced visualisation of the upper GI tract, and systematic endoscopic mapping should be conducted to improve detection. Sufficient examination time and structured training on diagnosis improves detection. Image enhanced endoscopy in addition to white light imaging improves detection of superficial upper GI cancer. Magnifying endoscopy with narrow-band imaging is recommended for characterisation of upper GI superficial neoplasms. Endoscopic characterisation can avoid unnecessary biopsy. CONCLUSION This consensus provides guidance for the performance of endoscopic diagnosis and characterisation for early gastric and oesophageal neoplasia based on the evidence. This will enhance the quality of endoscopic diagnosis and improve detection of early upper GI cancers.
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Affiliation(s)
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Rajvinder Singh
- Department of Gastroenterology, Lyell McEwin and Modbury Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Takuji Gotoda
- Department of Gastroenterology and Hepatology, Nihon University School of Medicine, Tokyo, Japan
| | | | - Kenshi Yao
- Department of Endoscopy, University Chikushi Hospital, Fukuoka, Japan
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Shiaw Hooi Ho
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Daisuke Kikuchi
- Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan
| | - Fang Yao
- Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Rapat Pittayanon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital The Thai Red Cross, Bangkok, Thailand
| | - Kenichi Goda
- Department of Gastroenterology, Dokkyo Medical University, Tochigi, Japan
| | - James Y W Lau
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong
| | - Hisao Tajiri
- Department of Innovative Interventional Endoscopy Research, Jikei University School of Medicine, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
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Effect of premedication on lesion detection rate and visualization of the mucosa during upper gastrointestinal endoscopy: a multicenter large sample randomized controlled double-blind study. Surg Endosc 2018; 32:3548-3556. [PMID: 29572630 PMCID: PMC6061056 DOI: 10.1007/s00464-018-6077-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 01/28/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Premedication in upper gastrointestinal endoscopy for higher lesions detection rate has not been well studied so far. This study aimed to confirm whether premedication could improve the detection rate of early cancer or precancerous lesions and mucosal visibility. METHOD From July 2015 to December 2015, 7200 participants from 6 centers were screened by endoscopy with one of the 4 following premedications randomly: (1) water (group D); (2) pronase (group A); (3) simethicone (group B); (4) pronase and simethicone (group C). Early cancer and precancerous lesions detection rates were taken as the primary endpoints, and mucosal visibility was taken as the secondary endpoint. They were compared among four groups to determine different premedication effects in terms of different anatomical sites. Trial was registered at Chinese Clinical Trial Registry; the registration number is ChiCTR-IOR-17010985. RESULTS The upper gastrointestinal overall precancerous lesion detection rates among four groups were 8.7, 8.4, 10.0, and 10.3%, the overall early cancer detection rates were 1.3, 1.4%, 1.5, and 1.6%, both without significant difference (p = 0.138 and 0.878). However, the visibility score distributions between control group (D) and premedication groups (A, B, and C) were all statistically significant, with all anatomical sites p values < 0.001. Subgroup analyses, from 2 centers without screening before, also showed significant difference in esophageal (3.9, 3.3, 4.5, and 8.4% with p = 0.004) and overall (7.0, 5.5, 7.3, and 12.0% with p = 0.004) precancerous lesion detection rate. CONCLUSIONS Premedication with pronase and simethicone may not increase lesion detection rates but could significantly increase the upper gastrointestinal mucosal visibility.
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