Endoscopic intermuscular dissection (EID) for removing early rectal cancers and benign fibrotic rectal lesions

In the current era of screening colonoscopy and increasing incidence of early rectal cancer, interventional endoscopy moves toward resections in deeper planes than the submucosal layer. Several reports support the use of endoscopic intermuscular dissection (EID) instead of endoscopic submucosal dissection (ESD) for the removal of deeply invasive rectal submucosal cancers. The resection plane into the intermuscular space, the space between the longitudinal (external) and circular (internal) muscle layer, allows radical removal of rectal invasive submucosal cancers. Furthermore, the technique offers the potential for dissection of scarred and severe fibrotic lesions in the rectum by cutting deeper and performing a partial myectomy avoiding the narrow submucosal space. We present 23 cases of EIDs both for deeply invasive rectal cancers and benign rectal lesions. This is the first report in the literature of EID resections for malignant and benign disease, including cases of severely fibrotic rectal lesions.

The natural history of COVID-19 in vaccinated inflammatory bowel disease patients

AIM

Assess the characteristics of break through COVID-19 in Inflammatory Bowel Disease (IBD) patients, despite complete vaccination.

METHODS

Patients who reported a COVID-19 at least 3 weeks after complete vaccination were asked to answer an on-line anonymous questionnaire which included patient and disease characteristics, vaccination history, and the evolution of COVID-19.

RESULTS

Among 3240 IBD patients who reported complete vaccination between 1st May 2021 and 30thJune 2022, 402 (12.4%) were infected by SARS Cov-2 [223 male, 216 Crohn's disease (CD), 186 Ulcerative Colitis (UC), mean (SD) age 42.3 (14.9) years, mean (SD) IBD duration 10.1 (9.7) years]. Three hundred and sixty-nine patients (91.8%) were infected once and 33 (8.2%) twice. The mean (SD) time between last vaccination and infection was 4.1 (1.6) months. Overall, 351 (87.3%) patients reported mild constitutional and/or respiratory symptoms, 34 (8.4%) were asymptomatic and only 17 patients (4.2%) required hospitalization. Of hospitalized patients, 2 UC patients died of COVID-19 pneumonia. The remaining hospitalized patients did not need high flow oxygen supply or ICU admission.

CONCLUSIONS

A minority of completely vaccinated IBD patients developed COVID-19 which evolved with mild symptoms and a favorable outcome. These results reinforce the importance of vaccination especially in vulnerable populations.

A prospective randomized comparison of cold vs hot snare polypectomy in the occurrence of postpolypectomy bleeding in small colonic polyps

AIM

Polypectomy techniques in the removal of polyps in the 3-8 mm size range are inconsistent. The aim of our study was to compare cold (CSP) with hot snare polypectomy (HSP) in the occurrence of postpolypectomy bleeding in small colonic polyps 3-8 mm in size.

METHOD

In all, 414 consecutive patients with small colorectal polyps 3-8 mm in size were prospectively randomized into the CSP group and the HSP group.

RESULTS

There was no early or late postpolypectomy bleeding in either group. Intraprocedural bleeding was significantly more frequent in the CSP group than the HSP group (CSP, 19/208; HSP, 2/206; P<0.001) but resolved spontaneously without any intervention in both groups.

CONCLUSION

The data show that the CSP technique is safe, effective and quicker than HSP for patients and it could be considered the ideal procedure for small polyp removal.

Deep sedation compared with moderate sedation in polyp detection during colonoscopy: a randomized controlled trial

AIM

The detection rate of adenomas is one of the current quality indicators in high-quality colonoscopy. We compared the performance of colonoscopy for the detection of polyps in patients sedated with deep and moderate sedation. Secondary objectives included the patient's and the endoscopist's satisfaction, recovery time and the adverse events related to sedation between the two groups.

METHOD

Five hundred and twenty patients submitted for colonoscopy were prospectively randomized into a deep sedation group (DS group, n = 258) and a moderate sedation (MS group, n = 262) group. In both, sedation and analgesia were performed using midazolam with pethidine.

RESULTS

There were no differences between the two groups in the following three areas: (1) The overall detection of polyps (DS, 1 [0-20]; MS, 1 [0-15]; P = 0.67), (2): polyp size ≥ 10 mm (DS, 0.00 [0-7]; MS, 0.00 [0-6]; P = 0.30), and (3) polyp size < 10 mm (DS, 0.00 [0-20]; MS, 0.00 [0-13]; P = 0.83). There was no significant difference in the rate of adenoma detection (DS, 1 [0-10]; MS, 1 [0-9]; P = 0.99).

CONCLUSION

The study demonstrated no difference in the detection of polyps by colonoscopy using deep or moderate sedation.

Comparison of standard vs high-definition, wide-angle colonoscopy for polyp detection: a randomized controlled trial

AIM

We sought to compare the performance of colonoscopy using a high-definition, wide-angle endoscope vs a standard colonoscope for the detection of polyps.

METHOD

A total of 390 patients were prospectively randomized into high-definition colonoscopy group (HD, n = 193) and standard colonoscopy group (SC, n = 197).

RESULTS

Analysis demonstrated that there were significant differences between the two groups, as far as the overall rate of polyps (SC, 1.31 ± 1.90; HD, 1.76 ± 2.31; P = 0.03) and the rate of small hyperplastic polyps (size < 5 mm; SC, 0.10 ± 0.36; HD, 0.25 ± 0.61; P = 0.003) were concerned. No significant differences between the two groups were observed, regarding large polyps (size ≥ 10 mm; SC, 0.39 ± 0.89; HD, 0.48 ± 0.80; P = 0.10), medium polyps (10 mm > size ≥ 5 mm; SC, 0.60 ± 1.46; HD, 0.58 ± 1.25; P = 0.31) and small polyps (size < 5 mm; SC, 0.32 ± 0.86; HD, 0.71 ± 1.65; P = 0.09). Similarly, no significant differences were demonstrated in the detection rate of adenomas and hyperplastic polyps, large adenomas, medium adenomas, small adenomas and large and medium hyperplastic polyps.

CONCLUSION

High-definition colonoscopy led to a significant increase in the polyp detection.

Level of intended sedation

Sedation and analgesia is the standard of care during diagnostic and therapeutic endoscopic gastrointestinal procedures in most areas of the world. Unsedated endoscopy is feasible in selected patients, but requires commitment on the part of both the patient and the provider. The American Society of Anesthesiologists has defined four stages of sedation, ranging from minimal to moderate, deep and general anesthesia. The level of sedation as well as the choice of sedative is based on the type of procedure, patient characteristics and the existence of the required structural conditions. Individuals administering sedation/analgesia should be trained to rescue a patient who has reached a level of sedation deeper than that intended.

Efficacy of bispectral index monitoring as an adjunct to propofol deep sedation for ERCP: a randomized controlled trial

BACKGROUND AND STUDY AIMS

We sought to determine whether bispectral index (BIS) monitoring is a useful adjunct to the administration of propofol titrated to deep sedation, as measured by reductions of doses of propofol administered during endoscopic retrograde cholangiopancreatography (ERCP).

PATIENTS AND METHODS

90 consecutive patients undergoing ERCP were randomized to receive propofol titrated to deep sedation, with the BIS value either visible (BIS group, n = 46) or invisible (control group, n = 44) to the anesthesiologist. In the BIS group, the anesthesiologist was instructed to use the BIS value as the primary end point for titration of sedation, and to target BIS values between 40 and 60. For the control group, the anesthesiologist was instructed to titrate propofol according to routine practice in the unit using the modified Observer's Assessment of Alertness/Sedation (MOAA/S) Scale (MOAA/S score 0).

RESULTS

The mean (SD) propofol doses (mg/min per kg weight) were 0.139 (0.02) and 0.193 (0.02) for the BIS and control groups, respectively (P < 0.001). Mean (SD) BIS values throughout the procedure were 61.68 (7.5) and 56.93 (4.77) for the BIS and control groups, respectively (P = 0.001). During the maintenance phase of sedation (MOAA/S score 0), the mean (SD) BIS values were 53.73 (8.67) and 45.65 (4.39) for the BIS and control groups, respectively (P < 0.001).

CONCLUSIONS

Our data suggest that BIS monitoring led to a reduction in the mean propofol dose when the BIS value was used as the primary target for sedation in ERCP procedures.

Endoscopic sedation in Greece: results from a nationwide survey for the Hellenic Foundation of gastroenterology and nutrition

BACKGROUND AND STUDY AIMS

Recent surveys regarding practices in sedation during endoscopic procedures are limited, particularly in Greece where they are nonexistent. This survey was designed to provide national data on sedation practices in Greece.

METHODS

A 27-item survey regarding practices of endoscopy and sedation was mailed nationwide to 502 members of the Hellenic Society of Gastroenterology.

RESULTS

A total of 201 questionnaires were returned (40%). Survey respondents performed an average of 48 oesophagogastroduodenoscopies (EGD) and 35 colonoscopies per month. 50 of the respondents, who perform endoscopic retrograde cholangiopancreatography (ERCP), conducted an average of 10 ERCP per month. 15 of the respondents, who perform endoscopic ultrasound (EUS), conducted an average of 6 EUS per month. Respondents administered sedation intravenously in 64% of EGD, 78% of colonoscopies, 100% of ERCP and 100% of EUS. 125 of the respondents (62.1%) reported the use of synergistic sedation (benzodiazepines plus opioids), 71 of the respondents (35.3%) reported the use of benzodiazepines alone and 68 of the respondents (33.8%) reported the use of propofol based sedation in selected cases (more than one response was permitted). In most cases, propofol administration was directed by an anaesthesiologist. The majority of the respondents monitored vital signs and pulse oximetry (90% and 96%, respectively).

CONCLUSION

The use of sedation and physiologic monitoring in Greece is now standard practice during endoscopy. Benzodiazepines, either alone or combined with an opioid, are used by the majority of endoscopists, while propofol is used in selected cases, mainly in the presence of an anaesthesiologist.