Can we shorten the small-bowel capsule reading time with the "Quick-view" image detection system?

BACKGROUND: The mean small-bowel capsule reading time is about 60 min, and shortening this reading time is a major aim. AIM: To evaluate the efficiency of the "Quick-view" detection algorithm. METHODS: Multicentre prospective comparative study. One hundred and six small bowel capsule films from 12 centres reviewed in Quick-view mode by 12 experienced readers. Reading time, image relevance, and comparison of Quick-view reading results to results of initial reading. Review of discordant result by 3 experts. RESULTS: The mean reading time in Quick-view mode was of 11.6 min (2-27). Concordant negative results were obtained in 41 cases (38.6%) and concordant positive results in 35 cases (33.0%). A discordant result was obtained in 30 (28.3%) cases: 21 false positive cases (initial reading 12 cases, Quick-view reading 9 cases), 14 false negative cases (initial reading 7, Quick-view 7). Four out of 7 lesions missed at Quick-view reading were not present on the Quick-view film (theoretical sensitivity 93.5%). CONCLUSION: The Quick-view informatic algorithm detected nearly 94% of significant lesions, and Quick-view reading was as efficient as the initial reading and much shorter. These results are to be confirmed by further studies, but suggest an excellent sensitivity for the Quick-view algorithm.

Prospective, randomized comparison of two small-bowel capsule endoscopy systems in patients with obscure GI bleeding.

BACKGROUND: Video capsule endoscopy is the first-intention examination in patients with obscure GI bleeding. The new MiroCam capsule, when using electric-field propagation for transmission, has been poorly evaluated in a clinical setting, in contrast with the PillCam SB2 capsule. OBJECTIVE: To evaluate the diagnostic concordance (κ value) between PillCam SB2 and MiroCam capsule examinations performed in the same patients. DESIGN AND SETTING: Prospective, randomized study in 7 endoscopy units. PATIENTS AND INTERVENTION: Eighty-three consecutive patients, ingesting the 2 capsules at a 1-hour interval. RESULTS: Seventy-three patients were analyzed (10 technical issues). There were 31 concordant negative cases (42.4%) and 30 concordant positive cases (41.1%). The study showed satisfactory diagnostic concordance between the 2 systems (κ = 0.66). In 12 patients (16.4%), the final diagnosis was different: 9 patients had positive findings on MiroCam examination but no image detected with PillCam SB2, 2 had positive findings on PillCam examination only, and 1 patient had 2 different diagnoses. A positive diagnosis was obtained in 46.6% and 56.2% of patients with PillCam SB2 and MiroCam capsule, respectively, so that the procedures identified 78.6% and 95.2% of positive cases, respectively (P = .02). Small-bowel transit time and capsule reading time were significantly longer in MiroCam procedures. LIMITATIONS: Technical failures possibly related to capsule interference. CONCLUSION: This study shows at least comparable efficiency of the MiroCam compared with the PillCam SB2 capsule system for the diagnosis of obscure GI bleeding.

Nonoperable patients with superficial esophageal cancer treated by photodynamic therapy after chemoradiotherapy have more severe complications than patients treated in primary intent.

INTRODUCTION: Photodynamic therapy (PDT) is a therapeutic option in patients with a superficial esophageal cancer. Recently, PDT was shown to be effective as a salvage therapy for a local recurrence after chemoradiotherapy (CRT). AIM: To compare retrospectively the results and the complications rate of PDT between consecutive patients treated in primary intent for a superficial esophageal cancer versus patients treated by PDT for a local recurrence after CRT. METHODS: Between 1999 and 2007 in a single center, 40 consecutive patients were treated by PDT for a superficial esophageal cancer, 25 (group 1) in primary intent and 15 (group 2) for a local recurrence after CRT. Two days after intravenous (IV) Photofrin (2 mg/kg), the phototherapy was performed with a dye laser. The treatment response and severe complications, defined as perforation and stricture requiring endoscopic dilation, were compared between the two groups. RESULTS: The patient and tumor characteristics were not different between the two groups. In group 1, 19 out of 25 patients (76%) were successfully treated versus 8 out of 15 patients (53%) in group 2 (P= 0.17). Severe complications occurred more frequently in patients with a prior CRT (8%vs 46.7%, P= 0.008) and included two perforations and five strictures requiring endoscopic dilation, while only two strictures occurred in group 1. A prior CRT was an independent risk factor of severe complications (odds ratio [OR] 8.05; 95% confidence interval [CI]1.22-43.0). CONCLUSIONS: Severe complications were significantly more frequent in patients treated after a prior CRT. PDT as a salvage therapy in patients with a local recurrence after CRT for esophageal cancer tended to be less efficient than in first-line treatment.

Capsule endoscopy and bowel preparation with oral sodium phosphate: a prospective randomized controlled trial.

BACKGROUND: Capsule endoscopy (CE) is the first procedure to explore the small bowel in obscure GI bleeding (OGB). OBJECTIVE: To evaluate the role of bowel preparation with oral sodium phosphate (NaP) in this indication. DESIGN: A prospective multicenter, controlled, randomized, blind study. METHODS: A total of 129 patients with the diagnosis of OGB were included and were randomized into 2 groups (group A [n = 64] and group B [n = 63]). In group A, a CE was performed after an 8-hour fasting period. In group B, patients were asked to drink 2 doses of 45 mL NaP before swallowing the capsule. The quality of the images was assessed at 5 different locations of the small bowel. Bowel cleanliness and visibility were evaluated by using 2 scoring systems, which included assessing the presence of bubbles, liquid, and the rate of visibility. RESULTS: A total of 127 patients (53 men; mean age 56.9 years, range 19-90 years) were analyzed for the preparation and detection of lesions (2 patients were not able to swallow the capsule). No difference was observed for cleanliness and visibility between the 2 groups at any of the small-bowel segments; no difference was found for gastric transit time (39.8 minutes vs 35.7 minutes, P = .63), small-bowel transit time (257.5 minutes vs 248.6 minutes, P = .59), and the detection of lesions (35.9% vs 42.8%, P = .54). LIMITATIONS: The evaluation of bowel cleanliness was based on subjective features. CONCLUSIONS: The results of the present study, despite a significant number of limitations, did not support that small-bowel preparation with oral NaP can be recommended for CE exploration in patients with OGB.

Bleeding gastric vascular ectasia treated by argon plasma coagulation: a comparison between patients with and without cirrhosis.

BACKGROUND: Gastric vascular ectasia (GVE) is an uncommon etiology of GI bleeding. GVE can affect not only patients with cirrhosis but also patients with a variety of chronic diseases. OBJECTIVE: The aim of the study was to compare clinical and endoscopic patient characteristics and responses to treatment by argon plasma coagulation (APC) of bleeding GVE between patients with cirrhosis and noncirrhotic patients. DESIGN: Retrospective study of consecutive patients. PATIENTS: Between January 2001 and December 2005, 30 patients were treated by APC for bleeding GVE. INTERVENTIONS: Clinical and endoscopic features and APC treatment success were compared between patients with cirrhosis (group 1) and noncirrhotic patients (group 2). MAIN OUTCOME MEASUREMENTS: Endoscopic treatment efficacy was assessed on the recurrence of symptoms after APC. RESULTS: Seventeen patients were cirrhotic and 13 had no cirrhosis. Cirrhotic patients presented more frequently with overt bleeding (65% vs 15%) and noncirrhotic patients with occult bleeding with iron deficiency anemia (35% vs 85%, P= .01). Endoscopy in noncirrhotic patients revealed more frequently a "watermelon" appearance (23.5% vs 76.9%, P= .008). Endoscopic treatment by APC was successful in 83.3% of patients (88.2% vs 76.9%, not significant). Patients from group 2 required significantly more APC sessions to achieve a complete treatment (2.18 vs 3.77, P= .04). CONCLUSIONS: APC treatment of bleeding GVE was efficient and safe in cirrhotic and noncirrhotic patients in more than 80% of cases. Noncirrhotic patients required significantly more APC sessions to achieve a complete treatment. An endoscopic watermelon appearance and the use of antiplatelet drugs were associated with failure of APC.

Multidetector CT in patients with esophageal stent as a palliative treatment for stenosing esophageal cancer: a feasibility study.

OBJECTIVE: The self-expanding metallic stent (SEMS) is widely used in the palliative treatment of stenosing esophageal cancer. Multidetector computed tomography (MDCT) allows volumetric investigation including virtual endoscopy. The aim of this study was to determine the feasibility of MDCT follow-up of esophageal SEMS and to describe the imaging patterns encountered as well as correlating them with fibroscopic evaluation. MATERIAL AND METHODS: Thirteen consecutive patients (10 M, mean age 64 years) with esophageal SEMS as a palliative treatment underwent MDCT for recurrent dysphagia (n =7), chest pain and fever (n = 1) or follow-up without symptoms (n = 5). Patency and esophageal wall patterns were studied and compared with diagnosis by fibroscopy. RESULTS: No metallic artefact related to the SEMS was observed. At the SEMS level, MDCT revealed a tissular lump (n = 1), a thin recurrent layer of tissue (n = 1), extrinsic compression (n = 1), fluid stasis (n =7) and intussusception of the gastric wall into the SEMS (n =4). The esophageal wall was analyzed by MDCT (peripheral thickening around the stent (n = 8), tumor overgrowth under or above the SEMS level (n = 8)) and showed tracheal compression (n = 3). At the level of the SEMS, fibroscopy showed tumor recurrence (n = 2), a thin recurrent layer of tissue (n = 1), a distorted SEMS (n = 1) and a tumor overgrowth under or above the SEMS level (n = 6). In comparison with fibroscopy, MDCT satisfactorily diagnosed the SEMS patency in 92% of cases and the esophageal wall in 73%. CONCLUSIONS: Morphology, patency of the SEMS and analysis of the esophageal wall can be performed by MDCT with a good degree of accuracy as compared to fibroscopy. In such patients in palliative care, a non-invasive investigation is worth promoting as a first-line procedure.

Colonic gas explosion during therapeutic colonoscopy with electrocautery.

Therapeutic colonoscopy with electrocautery is widely used around the world. Adequate colonic cleansing is considered a crucial factor for the safety of this procedure. Colonic gas explosion, although rare, is one of the most frightening iatrogenic complications during colonoscopy with electrocautery. This complication is the result of an accumulation of colonic gases to explosive concentrations, but may be prevented by meticulous bowel preparation. The purpose of this review is to discuss the indications and the types of bowel preparations for therapeutic colonoscopy, and to contribute recommendations for the adequate bowel preparation for colonoscopy with electrocautery.

Value of wireless capsule endoscopy in patients with indeterminate colitis (inflammatory bowel disease type unclassified).

BACKGROUND: Wireless capsule endoscopy (WCE) can identify small bowel mucosal lesions not seen with other imaging modalities. This technique can therefore play an important diagnostic role in the evaluation of patients with inflammatory bowel disease type unclassified (IBDU). We report on a multicentric study whose objective was to evaluate the value of WCE to increase diagnostic accuracy in categorizing IBDU. METHODS: Thirty patients with IBDU and negative serology were included. WCE was performed with a standard Pillcam capsule. Outcome measures were classified as suggestive of Crohn's disease (CD) when -3 ulcerations were present. RESULTS: WCE displayed endoscopic features suggestive for CD in 5 patients. In 6 other patients, WCE was negative, but repeated ileocolonoscopy with biopsies performed during follow-up evaluation revealed CD in 5 and ulcerative colitis (UC) in 1 patient. UC was found in a seventh case at colectomy performed just after WCE. Eighteen patients remained with a diagnosis of IBDU 16 months on average after WCE. CONCLUSIONS: WCE is a potentially clinically useful technique for categorizing a subgroup of patients with IBDU, although negative WCE does not exclude further diagnosis of CD. Patients with negative WCE who remain IBDU at follow-up evaluation may belong to an original subgroup of IBD.

Undernutrition is predictive of early mortality after palliative self-expanding metal stent insertion in patients with inoperable or recurrent esophageal cancer.

BACKGROUND: Self-expanding metallic stents (SEMS) are a first-line therapeutic procedure in the palliative treatment of dysphagia in patients with esophageal cancer. However, the impact of SEMS insertion on patient nutritional status has never been assessed. OBJECTIVE: To evaluate the nutritional status of patients after insertion of a SEMS and the impact of a preexisting undernutrition status on survival. DESIGN: Retrospective observational study. PATIENTS: A total of 120 patients treated in a single center by insertion of a SEMS for relief of dysphagia in the palliative treatment of esophageal cancer were retrospectively included. MAIN OUTCOME MEASUREMENTS: Efficacy of SEMS was assessed by the Ogilvie's dysphagia score. Patient nutritional and clinical statuses were evaluated at SEMS insertion, and patients were regularly followed until death. Independent predictive factors of early 30-day mortality were researched. RESULTS: Dysphagia scores decreased after SEMS insertion in 89.1% of patients, with median scores decreasing from 3.0 to 1.0 (P < .05). There was a significant decrease in body mass index (BMI) (P < .04), serum albumin level (P < .01), and World Health Organization (WHO) performance index (P < .02) at a 1-month evaluation. Serum albumin level, BMI <18 kg/m(2), and WHO performance index >2 at SEMS insertion were independent predictive factors of 30-day mortality. CONCLUSIONS: This study suggested that palliative stent placement in esophageal cancer was effective to relieve dysphagia but was not followed by an improvement of nutritional parameters. Moreover, it underlined the key role played by undernutrition on survival.

Predictive factors of survival in patients treated with definitive chemoradiotherapy for squamous cell esophageal carcinoma.

AIM: The aim of the study was to evaluate the predictive factors of survival in patients with locally advanced squamous cell esophageal carcinoma (LASCOC) treated with definitive chemoradiotherapy (CRT) regimen based on the 5FU/CDDP combination. METHODS: All patients with LASCOC treated with a definitive CRT using the 5FU/CDDP combination between 1994 and 2000 were retrospectively included. Clinical complete response (CCR) to CRT was assessed by esophageal endoscopy and CT-scan 2 mo after CRT completion. Prognostic factors of survival were assessed using univariate and multivariate analysis by the Cox regression model. RESULTS: A total of 116 patients were included in the study. A CCR to CRT was observed in 86/116 (74.1%). The median survival was 20 mo (range 2-114) and the 5-year survival was 9.4%. Median survival of responder patients to CRT was 25 mo (range 3-114) as compared to 9 mo (range 2-81) in non-responder patients (P < 0.001). In univariate analysis, survival was associated with CCR (P < 0.001), WHO performance status < 2 (P = 0.01), tumour length < 6 cm (P = 0.045) and weight loss < 10% was in limit of significance (P = 0.053). In multivariate analysis, survival was dependant to CCR (P < 0.0001), weight loss < 10% (P = 0.034) and WHO performance < 2 (P = 0.046). CONCLUSION: Our results suggest that survival in patients with LASCOC treated with definitive CRT was correlated to CCR, weight loss and WHO performance status.

Palliative esophageal stent placement using endoscopic guidance without fluoroscopy.

AIMS: Fluoroscopy is not available in every endoscopic unit. This situation leads to delays in treatment or to transfer of patients to other centres for stent insertion. We assessed safety and effectiveness of expandable esophageal metal stent placement under endoscopic control without fluoroscopy using a thin gastroscope. PATIENTS AND METHODS: From October 2002 to June 2004, thirty-three consecutive patients have been included for esophageal stent placement under endoscopic control alone with a nasogastroscope (5.9 mm). A proximal release covered stent (Ultraflex; Boston Scientific Microvasive) was used. Indications were malignant esophageal stricture (N = 26), malignant extrinsic compression (N = 2 ) and esophago-respiratory neoplastic fistulae (N = 5). RESULTS: Stent placement using endoscopic control alone was successful in 30/33 (90%) patients. Complications occurred in 11 patients. Early complications (<7 days) included one death from pulmonary embolism, severe retrosternal pain needing transient morphinic treatment (N = 2) and GERD despite antisecretory therapy (N = 1). Late complications included: food impaction (N = 1), tumour overgrowth-related obstruction of the stent (N = 5) and one late esophago-respiratory fistula at 4 months at the proximal end of the stent. Relief of dysphagia was obtained for all patients at 48 hours and dysphagia score decreased from 3.1 before stent to 1.2 at 1 month (P < 0.05). CONCLUSION: Expandable esophageal stents can be accurately and safely placed using endoscopy with a thin gastrosocope. This method obviates the requirement of fluoroscopic access, lacking in many centres, and avoids exposure to X-ray.

Factors that affect gastric passage of video capsule.

BACKGROUND: Gastric retention and delayed gastric emptying of the video capsule are major limitations. We retrospectively studied gastric transit time, gastric retention, and completeness of capsule endoscopy (CE) in relation to the conditions in which it was performed. METHODS: From May 2002 to September 2004, CE was performed in 190 patients (92 men; mean age, 58.4 years, range 16-91 years). Patients were stratified according to the way CE was performed (hospital day setting, outpatient, or ongoing hospitalization), and the recordings were analyzed to measure gastric retention, gastric transit time, and the completeness of the examinations. RESULTS: CE examination was performed in a hospital day setting in 100 patients, in an outpatient setting in 61, and during hospitalization in 29. Gastric retention of the capsule occurred in 8 of 190 patients (4.2%) (5 women, 3 men; mean age, 37.9 years). Gastric retention occurred during hospitalization in 7/29 (24.1%) and in hospital day setting in one of 100. Ongoing hospitalization was statistically associated with an increased risk of gastric capsule retention (p < 0.0001). The cecum was reached in 165/190 (87%), and ongoing hospitalization was associated with a lower rate of complete examinations (p < 0.001). Small-bowel transit time was similar, regardless of the circumstances of CE performance. CONCLUSIONS: Ongoing hospitalization is a major cause of gastric retention and incomplete examination by CE. Therefore, CE performance during ongoing hospitalization may require the use of a prokinetic agent.

Is a 2-liter PEG preparation useful before capsule endoscopy?

AIMS: Small bowel contents can sometimes hamper the quality of capsule images. Our aim was to investigate the effect of PEG administered prior to capsule endoscopy (CE) upon quality of images, gastrointestinal transit time, and detection rate of small bowel bleeding lesions in patients with obscure gastrointestinal bleeding. PATIENTS AND METHODS: Forty-two consecutive patients were included. CE was performed following a 12-hour fasting period. The 16 first patients (Group A) received no preparation and the following 27 patients (Group B) received 2 L of PEG the night before. The quality of images was assessed at both in duodenojejunum and ileum level, using a scale including the presence of air bubbles, biliary secretion, and residue (1-4). RESULTS: Quality of images were not different in Group A compared with Group B in the duodenojejunum and in the ileum. Gastric transit time tended to be shorter in Group A compared with Group B (25.5 vs. 45.7 minutes) (P = 0.15), whereas small bowel transit was not different between both groups (271 vs. 288 minutes). Total small bowel CE examination was complete in Group A and in 24 of 26 in Group B (not significant). Potential bleeding lesions were seen in 8 patients in Group A and 12 in Group B (not significant). CONCLUSION: Our retrospective study suggests that 2 L PEG preparation seems able to improve neither the quality of CE images nor its diagnostic performance. Moreover, in our study, PEG tended to increase gastric emptying time and may constitute a limitation for small bowel complete examination.

Does the "Suspected Blood Indicator" improve the detection of bleeding lesions by capsule endoscopy?

BACKGROUND: The "Suspected Blood Indicator" (SBI), a feature included in the software for interpretation of capsule endoscopy (CE), is designed to facilitate detection of bleeding lesions in the small bowel. This study evaluated the sensitivity and the specificity of the SBI in patients who underwent CE for obscure GI bleeding (OGIB). METHODS: CE recordings from patients with OGIB recruited in 7 centers were read by experts blinded to the red SBI tags. They classified lesions of interest as bleeding or as having a potential for bleeding that was high (P2), low (P1), or absent (P0). The SBI tags then were marked by a another investigator. Concordance was acknowledged when frames selected by the expert reader, and those tagged by the SBI had the same time code. RESULTS: A total of 156 recordings were evaluated. In 83, there was either no lesion (n = 71) or a P0 lesion (n = 12); these CE recordings were regarded as normal. Among the 73 abnormal recordings, 114 P2 and 92 P1 lesions were identified. A total of 154 red tags were analyzed. Sensitivity, specificity, and positive and negative predictive values of SBI were 37%, 59%, 50%, and 46%, respectively, for detection of the presence of a P2 or P1 lesion in front of a red tag. CONCLUSIONS: SBI-based detection of intestinal lesions with the potential for bleeding is of limited clinical value in practice and does not reduce the time required for interpretation of CE.

Diagnostic yield and therapeutic implications of capsule endoscopy in obscure gastrointestinal bleeding.

AIM: The main aim of this study was to evaluate efficacy and therapeutic impact of capsule endoscopy (CE) in obscure gastrointestinal bleeding (OGIB). In addition, we evaluated the software of automatic detection of red zones (SBI, Given Imaging). PATIENTS AND METHODS: From June 2002 to June 2003, thirty-five patients with OGIB underwent capsule endoscopy after negative upper and lower digestive endoscopy. Capsule endoscopy was performed following a 12-hour fasting period and some received 2 L of PEG the night before for bowel preparation. RESULTS: CE was performed for occult (N=18) or overt (N=17) OGIB. Potentially bleeding lesions were found in 16/35 patients (45.7%). Lesions were angiodysplasias (N=8), ulcerations (N=4), tumors (N=2) and active bleeding without visible lesion (N=2). Lesions were located in gastric antrum (N=1), duodenum (N=2) and jejuno-ileum (N=13). Endoscopic (N=10), surgical (N=2) or medical (N=1) treatments were performed in 13/35 (37%). SBI was retrospectively evaluated in 24 patients with sensitivity, specificity, positive and negative predictive value of respectively 45%, 73%, 50% and 69%. CE retention during 10 days occurred in a patient with a small bowel NSAID-induced stricture. CONCLUSION: CE is a safe and effective procedure in the management of OGIB and had a therapeutic impact in more than one third of patients.

Acute esophageal necrosis: a 1-year prospective study.

BACKGROUND: A prospective 1-year study was conducted to assess the frequency, clinical spectrum, histologic description, and follow-up of acute esophageal necrosis unrelated to ingestion of caustic or corrosive agents. METHODS: The diagnosis of acute esophageal necrosis was based on a diffusely black esophagus at endoscopy and typical histologic features of diffuse mucosal and submucosal necrosis. Ingestion of caustic and corrosive agents was excluded in all patients. Medical history, associated diseases, and clinical symptoms were recorded for each patient. Nutritional status was evaluated based on clinical and biochemical parameters. Treatment included short-term parenteral nutrition and intravenous administration of a pump proton inhibitor. A second endoscopy was performed when possible at 2 weeks after presentation to assess regression of acute esophageal necrosis. RESULTS: Among 3900 patients who underwent EGD, 8 (0.2%) with acute esophageal necrosis were identified. Nutritional status was poor for 6 patients. Complete resolution of acute esophageal necrosis without further recurrence was observed in 4. No esophageal strictures appeared during follow-up. Four patients died, but no death was directly related to acute esophageal necrosis. CONCLUSION: Acute esophageal necrosis is not as infrequent an endoscopic finding as has been reported. Acute esophageal necrosis appears to be associated with poor general health status and is not a purely local phenomenon.