Underwater cap-suction pseudopolyp formation for endoscopic mucosal resection: a simple technique for treating flat, appendiceal orifice or ileocecal valve colorectal lesions.

BACKGROUND: We aimed to evaluate the safety and technical success of an easy-to-use technique that applies underwater cap suction pseudopolyp formation to facilitate the resection of flat lesions or those at the appendiceal orifice or ileocecal valve. METHODS: We retrospectively analyzed a register of consecutive cap suction underwater endoscopic mucosal resection (CAP-UEMR) procedures performed at two centers between September 2020 and December 2021. Procedures were performed using a cone-shaped cap, extending 7 mm from the endoscope tip, to suction the lesion while submerged underwater, followed by underwater snare resection. Our primary end point was technical success, defined as macroscopic complete resection. RESULTS: We treated 83 lesions (median size 20 mm; interquartile range [IQR] 15-30 mm) with CAP-UEMR: 64 depressed or flat lesions (18 previously manipulated, 9 with difficult access), 11 from the appendix, and 8 from the ileocecal valve. Technical success was 100 %. There were seven intraprocedural bleedings and two delayed bleedings, all managed endoscopically. No perforations or other complications occurred. Among the 64 lesions with follow-up colonoscopy, only one recurrence was detected, which was treated endoscopically. CONCLUSIONS: CAP-UEMR was a safe and effective technique for removing nonpolypoid colorectal lesions, including those arising from the appendiceal orifice or ileocecal valve.

Appropriateness of routine pre-endoscopic SARS-CoV-2 screening with RT-PCR in asymptomatic individuals and its impact on delayed diagnosis.

AIMS: Endoscopy units are considered to be at an increased risk of infection by SARS-CoV-2. Our aim is to assess the correlation between pre-endoscopic screening with reverse-transcription-polymerase-chain-reaction (RT-PCR) in asymptomatic individuals scheduled for elective endoscopy and the epidemiological data published by the local Health Administration. PATIENTS AND METHODS: Observational retrospective study collecting the results of our screening strategy spanning June/2020-June/2021, the effective potential growth (EPG), an index measuring the outbreak risk, and the 7 and 14-day cumulative incidence (CI). Indication, delay and the findings of the endoscopic examinations were registered for RT-PCR positive patients. RESULTS: A total of 5808 tests were performed, yielding 125 positive results (2.15%). All positive tests occurred in weeks of high/very high risk (EPG>100) with the highest monthly rate being 9.36%, recorded in January/2021. A significant correlation (rho=0.796; p<0.001) between weekly positive rates and EPG was observed, and a significantly lower weekly number of positive tests was recorded when EPG<100. Planning the screening strategy one week ahead according to EPG>100 would have avoided up to 826 tests with only one positive result to account for. One hundred and thirteen individuals tested positive and 89 endoscopies were delayed. The most common findings were colon polyps, colorectal cancer and gastric metaplasia. Oncological diagnosis was delayed 50±3 days. CONCLUSIONS: No positive RT-PCR test were registered out of high-risk periods. Epidemiological administrative data in the preceding two weeks showed a significant correlation with screening results and could be useful to plan pre-endoscopic screening and avoid unnecessary tests.

Endoscopic Shielding With Platelet-rich Plasma After Resection Of Large Colorectal Lesions.

BACKGROUND: Platelet-rich plasma (PRP) has demonstrated efficacy as submucosal injection before endoscopic mucosal resection or local injection after endoscopic submucosal dissection of nonpedunculated colorectal lesions. METHODS: The EndoPRP study was a prospective single-center study to analyze the efficacy of PRP shield after endoscopic mucosal resection of large nonpedunculated colorectal lesio with impossible clip closure, assessed by the incidence of delayed bleeding (DB) and delayed perforation, and percentage of mucosal restoration after 4 weeks (mucosal healing rate). RESULTS: Shielding technique with PRP was performed in 4 patients, aged 52 to 80, with 4 lesions at rectum (mean size 53.7±20.6 mm, range 35 to 80 mm). DB occurred in 1 lesion (25% of all lesions), no required blood transfusion or endoscopic treatment. No postoperative delayed perforation occurred. Mucosal healing rate was of 78.6% after 4 weeks. CONCLUSIONS: PRP shield failed in prevent DB, probably due to migration and failure in the adherence in large wounds. Future comparative studies are needed to confirm these data.

Endoscopic shielding technique with a newly developed hydrogel to prevent thermal injury in two experimental models.

BACKGROUND AND AIM: A newly developed hydrogel, applied through the endoscope as an endoscopic shielding technique (EndoSTech), is aimed to prevent deep thermal injury and to accelerate the healing process of colonic induced ulcers after therapeutic endoscopy. METHODS: Lesions were performed in rats (n = 24) and pigs (n = 8). Rats were randomized to receive EndoSTech (eight rats each) with: saline (control), hyaluronic acid and product. In pigs, three ulcer sites were produced in each pig: endoscopic mucosal resection (EMR)-ulcer with prior saline injection (A; EMR-saline), EMR-saline plus EndoSTech with product (B; EMR-saline-P), and EMR with prior injection of product plus EndoSTech-P (C; EMR-P-P). At the end of the 14-day study, the same lesions were performed again in healthy mucosa to assess acute injury. Animals were sacrificed after 7 (rats) and 14 (pigs) days. Ulcers were macroscopically and histopathologically evaluated. Thermal injury (necrosis) was assessed with a 1-4 scale. RESULTS: In rats, treatment with product improved mucosal healing comparing with saline and hyaluronic acid (70% vs 30.3% and 47.2%; P = 0.003), avoiding mortality (0% vs 50% and 25%; P = 0.038), and perforation (0% vs 100% and 33.3%; P = 0.02); respectively. In pigs, submucosal injection of product induced a marked trend towards a less deep thermal injury (C = 2.25-0.46 vs A and B = 2.75-0.46; P = 0.127). Mucosal healing rate was higher with product (B = 90.2-3.9%, C = 91.3-5.5% vs A = 73.1-12.6%; P = 0.002). CONCLUSIONS: This new hydrogel demonstrates strong healing properties in preclinical models. In addition, submucosal injection of this product is able to avoid high thermal load of the gastrointestinal wall.

Efficacy of platelet-rich plasma as a shielding technique after endoscopic mucosal resection in rat and porcine models.

BACKGROUND AND STUDY AIMS: The aims were to assess the efficacy of endoscopic application of Platelet-rich plasma (PRP) to prevent delayed perforation and to induce mucosal healing after endoscopic resections. PATIENTS AND METHODS: Colonic induced lesions were performed in rats (n = 16) and pigs (n = 4). Animals were randomized to receive onto the lesions saline (control) or PRP. Animals underwent endoscopic follow-up. Thermal injury was assessed with a 1 - 4 scale: (1) mucosal necrosis; (2) submucosal necrosis; (3) muscularis propria necrosis; and (4) serosal necrosis RESULTS: Saline treatment showed 50 % of mortality in rats (P = 0.02). Mean ulcerated area after 48 hours and 7 days was significantly smaller with PRP than with saline (0.27 ±â€Š0.02 cm(2) and 0.08 ±â€Š0.01 cm(2) vs. 0.56 ±â€Š0.1 cm(2) and 0.40 ±â€Š0.06 cm(2); P < 0.001). The incidence of thermal injury was significantly lower with PRP (1.25 ±â€Š0.46) than in controls (2.25 ±â€Š0.50); P = 0.006. The porcine model showed a trend toward higher mucosal restoration in animals treated with PRP than with saline at weeks 1 and 2 (Median area in cm(2): 0.55 and 0.40 vs. 1.32 and 0.79) CONCLUSIONS: Application of PRP to colonic mucosal lesions showed strong healing properties in rat and porcine models.

Improving the quality of colonoscopy bowel preparation using a smart phone application: a randomized trial.

BACKGROUND AND AIM: Getting ready for a colonoscopy is difficult and involves many steps. Information given to patients is very important for adherence to treatment. We created a novel smart phone application (SPA) aimed to increase bowel preparation quality and patient satisfaction. METHODS: We carried out a prospective, endoscopist-blinded, randomized, controlled trial. We enrolled 260 outpatient (58% female, age range 21-75 years) owners of a smartphone. Patients were allocated to two different protocols: instructions provided by SPA (SPA group; n = 108) or written instructions with visual aids (control group; n = 152). All procedures were carried out in the afternoon and patients received the same purgative regimen (2 L polyethylene glycol (PEG) solution plus ascorbic acid), in a full-dose same-day regimen. The study was designed to detect an improvement in quality of bowel preparation using the Harefield Cleansing Scale (HCS) scale. Effect of protocol on patient satisfaction was assessed with a specific questionnaire at the time of colonoscopy. RESULTS: Proportion of patients who obtained successful bowel preparation for colonoscopy (HCS A or B) was significantly higher in the SPA group than in the control group (100% vs 96.1%, respectively; P = 0.037). Mean global HCS scores were similar in both groups. Patient-reported tolerability and overall experience with the prescribed bowel preparation were significantly higher for the SPA group than for the control group. CONCLUSION: Successful cleansing and patient acceptability with the use of SPA were superior to written instructions in outpatients submitted for colonoscopy using 2 L PEG solution plus ascorbic acid.

Biodegradable stents in gastrointestinal endoscopy.

Biodegradable stents (BDSs) are an attractive option to avoid ongoing dilation or surgery in patients with benign stenoses of the small and large intestines. The experience with the currently the only BDS for endoscopic placement, made of Poly-dioxanone, have shown promising results. However some aspects should be improved as are the fact that BDSs lose their radial force over time due to the degradable material, and that can cause stent-induced mucosal or parenchymal injury. This complication rate and modest clinical efficacy has to be carefully considered in individual patients prior to placement of BDSs. Otherwise, the price of these stents therefore it is nowadays an important limitation.

Microperforation of the colon: animal model in rats to reproduce mucosal thermal damage.

BACKGROUND: The aim of the present study was to develop a rat model of colonic microperforation secondary to thermal injury for future studies to assess new treatments. METHODS: Twenty-four male Sprague-Dawley rats were used in this study. Hot biopsy forceps were used for all treatments. All lesions were created in proximal left colon using the soft coagulation setting. The power setting tested was 40 W, and the durations of monopolar soft coagulation application evaluated were 2, 3, and 4 s. RESULTS: In the acute phase, 48 h after thermal injury, durations of cautery of 2 and 3 s resulted in transmural necrosis, whereas with 4 s microperforation was obtained. In the late phase, 7 d after the damage, only duration of cautery of 4 s showed deep cautery effects, with signs of peritonitis. CONCLUSIONS: We determined optimal power settings and duration of therapy in a rat model for producing electrocautery that involves transmural necrosis with microperforation.

Predictive factors of radiation dose in ERCP: a prospective study in 2 tertiary centers.

BACKGROUND: The use of fluoroscopy to aid endoscopic retrograde cholangiopancreatography (ERCP) places both the patient and the endoscopy staff at the risk of radiation-induced injury. Previous reports have demonstrated a linear relationship between radiation dose and fluoroscopy duration. AIM: To identify predictive factors of fluoroscopy time and radiation exposure to patients undergoing ERCP by using pulsed fluoroscopy. METHODS: Four hundred and four consecutive ERCPs performed from January 2010 to November 2010 at 2 tertiary centers in Spain were prospectively studied. Patients and procedural variables were analyzed. Philips BV Pulsera mobile fluoroscopy system was used on the endoscopy unit. Entrance surface dose, dose-area product, and fluoroscopy time were recorded for each patient. RESULTS: A total of 404 ERCPs on 404 consecutive patients were studied (mean age 73 y). The average entrance surface dose and dose-area product were 12.0 mGy and 0.37 mGy/m2, respectively. Mean fluoroscopy time was 2.31 minutes. The biliary ducts were adequately visualized in 371 (92%) cases. After analysis with a univariable model, the factors found to significantly increase the radiation dose (P75>19.6 mGy) were as follows: alkaline phosphatase serum levels (P=0.047), balloon dilation (P=0.005), biliary stent placement (P=0.001), and ERCP diagnosis (P=<0.0001). In a multivariate analysis, only stent insertion significantly increased the radiation dose (risk ratio 4.75; 95% confidence interval, 1.84-7.63). CONCLUSIONS: In this prospective analysis, multiple factors affected the radiation dose. Stent insertion was the only independent predictor significantly associated with prolonged fluoroscopy.

[Preparation for colonoscopy: types of scales and cleaning products]. / Preparación para colonoscopia: tipos de productos y escalas de limpieza.

Adequate bowel preparation is essential before a colonoscopy, allowing us to make a proper examination of the entire mucosa. The ideal method of colon cleansing should be fast, safe, and get a proper cleaning with minimal discomfort for the patient. Today we have a wide variety of colon cleansing products, information sometimes becomes confused. A good colon preparation depends partly on correct choice of the same, but also upon dietary restriction. Knowledge of all these products, with their advantages and limitations, we can make a better selection for each patient, and although the efficacy is comparable, is the experience of the browser, patient preferences, and the degree of compliance with the instructions preparation, which greatly influence the results.

Preparación para colonoscopia: tipos de productos y escalas de limpieza / Preparation for colonoscopy: types of scales and cleaning products

Una adecuada preparación del colon es fundamental antes de realizar una colonoscopia, ya que nos permite realizar una correcta exploración de toda la mucosa. El método ideal de limpieza del colon debe ser rápido, seguro y conseguir una limpieza apropiada con las mínimas molestias para el paciente. En la actualidad disponemos de una amplia variedad de productos de limpieza de colon, información que en ocasiones llega a ser confusa. Una buena preparación del colon depende por una parte de una correcta elección del mismo, pero también de una restricción dietética previa. El conocimiento de todos estos productos, con sus ventajas y limitaciones, nos permite hacer una mejor selección para cada paciente; y aunque la eficacia sea comparable, es la experiencia del explorador, las preferencias del paciente y el grado de cumplimiento de las instrucciones de preparación, las que influyen notablemente en los resultados(AU)

Adequate bowel preparation is essential before a colonoscopy, allowing us to make a proper examination of the entire mucosa. The ideal method of colon cleansing should be fast, safe, and get a proper cleaning with minimal discomfort for the patient. Today we have a wide variety of colon cleansing products, information sometimes becomes confused. A good colon preparation depends partly on correct choice of the same, but also upon dietary restriction. Knowledge of all these products, with their advantages and limitations, we can make a better selection for each patient, and although the efficacy is comparable, is the experience of the browser, patient preferences, and the degree of compliance with the instructions preparation, which greatly influence the results(AU)

Manejo endoscópico de las estenosis luminales en la enfermedad inflamatoria intestinal / Endoscopic management of luminal stenosis in inflammatory bowel disease

Resumen La estenosis luminal es más frecuente en la enfermedad de Crohn (EC) dado su compromiso transmural. Antes de proceder a cualquier tratamiento endoscópico se debe descartar la presencia de una estenosis neoplásica. La dilatación endoscópica con balón se ha utilizado en varias series como tratamiento de las estenosis benignas, principalmente en EC con afectación del de íleon distal, colon o anastomosis quirúrgicas, con un éxito de entre el 51 y el 85%, aunque la recurrencia es alta. El uso concomitante de esteroides inyectados (triamcinolona) tras la dilatación endoscópica muestra unos resultados más duraderos, aunque la experiencia publicada es escasa. Ante pacientes con estenosis luminal resistente a la técnica convencional, disponemos de 3 técnicas endoscópicas emergentes que pueden ser de utilidad: stents metálicos autoexpandibles, endoprótesis biodegradables e inyección intralesional de infliximab (AU)

Abstract Luminal stenosis is frequent in Crohn's disease (CD) due to transmural involvement. Before any endoscopic treatment, the presssence of neoplastic stenosis should always be excluded. Endoscopic balloon dilatation has been used in several series to treat benign stenosis, mainly in CD with involvement of the distal ileon, colon or surgical anastomosis, with success rates of 51% to 85%, although recurrence is high. The concomitant use of injected steroids (triamcinolone) after endoscopic dilatation produces longer-lasting results, but there are few published reports. In patients with luminal stenosis refractory to conventional endoscopy, three emerging techniques may be useful: self-expanding metallic stents, biodegradable endoprostheses and intralesional infliximab injection (AU)

[Endoscopic management of luminal stenosis in inflammatory bowel disease]. / Manejo endoscópico de las estenosis luminales en la enfermedad inflamatoria intestinal.

Luminal stenosis is frequent in Crohn's disease (CD) due to transmural involvement. Before any endoscopic treatment, the presence of neoplastic stenosis should always be excluded. Endoscopic balloon dilatation has been used in several series to treat benign stenosis, mainly in CD with involvement of the distal ileon, colon or surgical anastomosis, with success rates of 51% to 85%, although recurrence is high. The concomitant use of injected steroids (triamcinolone) after endoscopic dilatation produces longer-lasting results, but there are few published reports. In patients with luminal stenosis refractory to conventional endoscopy, three emerging techniques may be useful: self-expanding metallic stents, biodegradable endoprostheses and intralesional infliximab injection.

High-definition colonoscopy and risk factors for recurrence of advanced adenomas in patients with a personal history of polyps.

BACKGROUND AND AIMS: Postpolypectomy surveillance is one of the most common reasons for performing colonoscopy. Our purpose was to assess characteristics of basal adenomas related to the recurrence of advanced adenomas, and to compare the patterns observed in recurrent adenomas with the use of conventional colonoscopy (CC) (1995-1998 period) or high-definition colonoscopy (HDC) (2005-2008 period). METHODS: Analyses were based on 612 patients with recurrent adenomas (n=306) or no adenomas (control group; n=306), with at least two follow-up colonoscopies. A total of 56 patients with recurrent adenomas during the 1995-1998 period were compared with 116 patients in the 2005-2008 period. Morphology, size, location, and pathological diagnosis of each polyp were recorded. Multiple logistic regressions were used to calculate relative risk (RR) for recurrence. RESULTS: The study population was predominantly male (68.8%), with a mean age of 61.1 years and a mean follow-up period of 90.6±59.4 months. Advanced adenomas were found during follow-up evaluation in 120 patients (39.2%). The RR of advanced adenoma recurrence was 1.64 [95% confidence interval (CI): 1.01-2.64] among patients with baseline high-risk adenoma and 0.61 (CI: 0.38-0.98) among those with baseline low-risk adenoma. In the multivariable analyses, patients with larger adenomas were more likely to develop advanced recurrence (RR 1.02; 95% CI: 1.01-1.04). Both techniques (CC and HDC) detected a similar number (2.37±3.28 vs. 3.11±4.63; P=0.406) at qualifying colonoscopy. During follow-up both periods showed comparable adenoma characteristics. CONCLUSION: Patients with larger adenomas were more likely to develop advanced recurrence. HDC did not detect significantly more adenomas than CC. Characteristics of recurrent adenomas were comparable in both periods.

Adecuación de la indicación de la colonoscopia según los nuevos criterios de EPAGE II / Appropriateness of colonoscopy indications according to the new EPAGE II criteria

IntroducciónLos criterios europeos para el uso apropiado de la endoscopia (EPAGE) han sido actualizados este año (EPAGE II), pero aún no han sido evaluados.Objetivos(1) Analizar la adecuación de las colonoscopias según los criterios de EPAGE II y (2) evaluar su correlación con el diagnóstico.Pacientes y métodosAnálisis retrospectivo de 700 colonoscopias (48% hombres, edad media 58 años). Se excluyeron 45 (6,4%) por preparación insuficiente o indicación electiva. Según EPAGE II se consideró la prueba «apropiada», «no apropiada» o «incierta».Resultados94% (n=655) fueron evaluables, siendo el cribado de cáncer colorectal (CCR) el motivo de indicación más frecuente (19%). El 70% de las pruebas fueron «apropiadas», y un 18% «no apropiadas», con diferencias significativas según el origen de la petición. Control postpolipectomía fue la indicación más inapropiada por acortamiento en los plazos de realización. En el 48% se evidenció diagnóstico endoscópico, encontrando la presencia lesiones relevantes —CCR, adenomas, enfermedad inflamatoria (EII), angiodisplasias y estenosis benignas—en el 25% de ellas (n=167). El cribado de CCR (17,3%) y el control tras polipectomía (16,7%) fueron las indicaciones más asociadas con la presencia de diagnóstico relevante, aunque sin significación. La única indicación que se asoció al diagnóstico de CCR fue la anemia ferropénica (p<0,001).ConclusiónUn 18% de las colonoscopias solicitadas son inapropiadas y un 12% inciertas. La anemia ferropénica es la indicación con mayor correlación para el diagnóstico de CCR. Los criterios de EPAGE II presentan una buena asociación con el diagnóstico endoscópico de CCR (AU)

IntroductionThe appropriateness criteria for colonoscopy developed by a European expert panel (EPAGE), published in 1999, were revised this year (EPAGE II), but have not yet been evaluated.Objectives(1) To analyze colonoscopies performed at our hospital, and (2) to evaluate the appropriateness of the new EPAGE II criteria.Patients and methodsWe retrospectively analyzed 700 colonoscopies (48% males, mean age 58 years). Forty-five colonoscopies (6.4%) were excluded for insufficient bowel preparation or elective indication. EPAGE II criteria classified colonoscopies as “appropriate”, “inappropriate” and “uncertain”.ResultsNinety-four percent (n=655) of colonoscopies were evaluated. The most frequent indication for colonoscopy (19%) was screening of colorectal cancer (CRC). Seventy percent of colonoscopies were “appropriate”, and 18% were “inappropriate”, with significant differences according to where the request was made. The most inappropriate indication was postpolypectomy follow-up, due to shorter follow-up intervals. An endoscopic diagnosis was made in 315 patients (48%), with a finding of significant lesions in 25% (n=167; CCR, adenomas, inflammatory bowel disease, angiodysplasia and benign stricture). The indications most frequently associated with relevant findings were screening of CRC (17.3%) and postpolypectomy follow-up (16.7%) but this association was non-significant. Only iron-deficiency anemia was significantly associated with CRC (p<0.0001).ConclusionsEighteen percent of requests for colonoscopy were inappropriate and 12% provided incomplete information. The indication most strongly associated with a diagnosis of CRC was iron-deficiency anemia. The EPAGE II criteria showed a significant correlation with an endoscopic diagnosis of CRC (AU)

[Appropriateness of colonoscopy indications according to the new EPAGE II criteria]. / Adecuación de la indicación de la colonoscopia según los nuevos criterios de EPAGE II.

INTRODUCTION: The appropriateness criteria for colonoscopy developed by a European expert panel (EPAGE), published in 1999, were revised this year (EPAGE II), but have not yet been evaluated. OBJECTIVES: (1) To analyze colonoscopies performed at our hospital, and (2) to evaluate the appropriateness of the new EPAGE II criteria. PATIENTS AND METHODS: We retrospectively analyzed 700 colonoscopies (48% males, mean age 58 years). Forty-five colonoscopies (6.4%) were excluded for insufficient bowel preparation or elective indication. EPAGE II criteria classified colonoscopies as "appropriate", "inappropriate" and "uncertain". RESULTS: Ninety-four percent (n=655) of colonoscopies were evaluated. The most frequent indication for colonoscopy (19%) was screening of colorectal cancer (CRC). Seventy percent of colonoscopies were "appropriate", and 18% were "inappropriate", with significant differences according to where the request was made. The most inappropriate indication was postpolypectomy follow-up, due to shorter follow-up intervals. An endoscopic diagnosis was made in 315 patients (48%), with a finding of significant lesions in 25% (n=167; CCR, adenomas, inflammatory bowel disease, angiodysplasia and benign stricture). The indications most frequently associated with relevant findings were screening of CRC (17.3%) and postpolypectomy follow-up (16.7%) but this association was non-significant. Only iron-deficiency anemia was significantly associated with CRC (p<0.0001). CONCLUSIONS: Eighteen percent of requests for colonoscopy were inappropriate and 12% provided incomplete information. The indication most strongly associated with a diagnosis of CRC was iron-deficiency anemia. The EPAGE II criteria showed a significant correlation with an endoscopic diagnosis of CRC.