Timed screening colonoscopy: a randomized trial of two colonoscopic withdrawal techniques.

BACKGROUND AND GOALS: Missed adenomas are likely to be located in the proximal colon and failure to detect these lesions might explain the occurrence of a certain percentage of interval carcinomas. Though studies have demonstrated increased detection of significant neoplastic lesions in colonoscopic examinations where the withdrawal time is 6 min or more, there are no recommendations on how much time to spend in each colonic segment. The aim of the trial was to find ways to reduce the number of lesions missed in the proximal segments of the colon assessing the difference in adenoma detection rate (ADR) between two colonoscopic withdrawal timed techniques. STUDY: This was a randomized trial in a university hospital. Population was composed of patients referred for screening colonoscopy. The Main Outcome measurements was ADRs for patients subjected to a timed colonoscopy with specific withdrawal times, with special interest in the proximal colon, and implying a minimum of 2-min withdrawal delay in the cecum and right colon, a 1-min delay time in the transverse colon, and a minimum additional 3-min delay time in the left colon, as compared to a standard timed colonoscopy with free withdrawal delay time of at least 6 min. RESULTS: A total of 1160 patients were included. Eleven were initially excluded due to incomplete colonoscopies. Of the remaining 1149 patients, 573 were randomized to the group with fixed withdrawal times (Group A) and 576 to conventional withdrawal (Group B). Median age was 57 years (SD 6), a total of 634 (55.2%) were male patients and the mean withdrawal time was 7:05 min (SD 1 min). Seven hundred and eighty-one adenomas/serrated lesions were found in 470 patients (1.66 per patient), with 28 advanced lesions and 3 adenocarcinomas. Global ADR was 41% with no significant statistical differences between the two groups (42.1% vs 39.8%, p 0.43), respectively. A multivariate analysis showed clear relation between the finding of adenomas and higher BBPS ratings (Adjusted Odds Ratio [aOR] 0.92, p 0.05), age (aOR 1.03, p 0.01), male sex (aOR 1.51, p 0.001), and time of withdrawal (aOR 1.17, p 0.001), while no association was observed with either withdrawal technique (aOR 0.89, IC 95% 0.70-1.03, p 0.32). There was no statistical significant difference between the two groups concerning the finding of proximal lesions (cOR 0.93, CI 95% 0.71-1.20, p 0.56) (aOR 0.89, CI 95% 0.69-1.17, p 0.41) or serrated polyps (cOR 0.81, CI 95% 0.51-1.27, p 0.35) (aOR 0.81, IC 95% 0.51-1.28, p 0.36). CONCLUSIONS: Fixed withdrawal times did not prove to lead to an increase in the number of detected adenomas. Nevertheless, our study supports previous reports stating that longer withdrawal times are indeed associated with better proximal and distal adenoma detection.

Risk of colorectal neoplasia in patients with celiac disease: a multicenter study.

BACKGROUND AND AIMS: The association of celiac disease with colorectal neoplasia is controversial. The aim of this study was to determine the risk of colorectal neoplasia among patients with celiac disease. METHODS: We carried out a multicenter, retrospective case-control study, within four community hospitals. Celiac disease patients with a complete colonoscopy were regarded as cases and those without celiac disease as controls. For each case, two controls matched for age, sex, indication for colonoscopy and colorectal cancer family history, were randomly selected. The main outcome evaluated was risk of colorectal polyps, adenomas, advanced neoplastic lesions and cancer. RESULTS: We identified 118 patients with celiac disease and 236 controls. The risk of polyps, adenomas and advanced neoplastic lesions was similar in both groups (OR 1.25, CI 0.71-2.18, p=0.40; OR 1.39, CI 0.73-2.63, p=0.31; and OR 1.00, CI 0.26-3.72, p=1.00, respectively). On multivariate analysis, age >75 years old, and first-grade CRC family history were associated with adenomas (OR 2.68 CI 1.03-6.98, OR 6.68 CI 1.03-47.98 respectively) and advanced neoplastic lesions (OR 15.03, CI 2.88-78.3; OR 6.46 CI 1.23-33.79, respectively). With respect to celiac disease characteristic, a low adherence to a gluten free diet was independently associated with the presence of adenomas (OR 6.78 CI 1.39-33.20 p=0.01). CONCLUSIONS: Celiac disease was not associated with an increased risk of colorectal neoplasia. Nonadherence to a strict gluten free diet was associated with the presence of adenomas. Further studies addressing celiac disease characteristics are needed to confirm this observation.

[Bowel preparation for colonoscopy: comparative study using Boston Bowel Preparation Scale]. / Estudio comparativo de tres preparaciones para colonoscopía utilizando la escala Boston Bowel Praparation Scale.

BACKGROUND: Most comparative studies on different preparations for colonic cleanliness use unvalidated scales with terms as "excellent," "good," "fair," and "poor" which lack standardized definitions. The Boston Bowel Preparation Scale (BBPS) is a valid and simple measure of bowel preparation. OBJECTIVE: To compare three different bowel preparations [polyethylenglycol (PEG), sodium phosphates, and PEG + bisacodyl tablets] using BBPS. MATERIAL AND METHODS: Patients undergoing screening colonoscopies were included during a period of 6 months. Every patient was scored according to BBPS. RESULTS: Six endoscopists prospectively enrolled 374 patients (200 female and 174 male, median age 56.9 years old). Physicians chose the preparation method, and in spite of not being a randomized trial, numbers in each group allowed statistical analysis: PEG 116patients (31%), sodium phosphates 212 (56.7%) and bisacodyl 46 (12.3%). There was statistical difference between the three preparations in favor of the 4 litre solution of PEG, with a median score of 7, towards sodium phosphates and bisacodyl, with median scores of 6 (P < 0.001). Depending on bowel preparation, there were positive polyp findings in 40% of colonoscopies with PEG, 26% with sodium phosphates and 22% with bisacodyl (P = 0.01). Afternoon procedures had better preparation scores than morning procedures, 7 and 6, respectively (P < 0.001). In the afternoon colonoscopies, there were no statisticaIly significant differences between the preparations (P = 0.12) or polyp findings (P = 0.13). In the morning shift, PEG prepared patients had better scores (score of 6) when compared to sodium phosphate (score of 5) and bisacodyl (score of 6) (P = 0.001). We also noticed that the shorter the time interval between the last intake of the preparation and the procedure, the better the score. CONCLUSIONS: Bowel preparations for colonoscopy with PEG are significantly better than sodium phosphate and bisacodyl preparations, with higher BBPS scores and polyp detection rates.

Primary amelanotic melanoma of the esophagus.

Primary melanoma of the esophagus (PME) is an uncommon malignancy with less than 250 cases reported in the literature. Amelanotic PME is exceedingly rare and accounts for 10-25% of melanomas of the esophagus. A 59-year-old male with a history of mild dysphagia, heartburn, moderate anorexia and weight loss for 1 month is described. Barium swallow examination and videogastroscopy showed a polypoid, ulcerated mass located 30-38 cm from the incisors. No skin or eye melanoma lesions were found. Five biopsy samples were obtained. Histological examinations revealed proliferation of large, loosely cohesive cells of variable shapes and prominent central nucleoli in the deep mucosa. Immunohistochemical findings included positive vimentin, protein S-100, Melan A, and HMB-45, and negative AE1/AE3, CD 17, and desmin. A total transhiatal esophagectomy with high cervical esophagogastric anastomosis was performed. Peritumoral lymph nodes revealed malignant invasion. A diagnosis of primary amelanotic melanoma of the esophagus was made. Fourteen months after diagnosis the patient developed disseminated PME.

Tratamiento endoscópico de la litiasis de la vía biliar principal / Endoscopic treatment of the lithiasis of the common bile duct

Se describe la experiencia de 10 años en el tratamiento de la vía biliar principal por esfinteropapilotomía endoscópica. En 501 pacientes se efectuaron 487 esinteropapilotomía endoscópicas satisfactorias (97,2%) y se fracasó en 14. Cuarenta y dos enfermos presentaron una complicación precoz vinculada al procedimiento (8,62%): hemorragía en 20 casos (4,1%), colangitis aguda en 11. Hubo 5 perforaciones, 2 pancreatitis agudas y en una pacientes la canastilla se atascó en la vía biliar. Se observaron 34 complicaciones alejadas: 31 litiasis residuales postesfinteropapilotomía endoscópica, 2 colecistitis agudas a los 14 y 20 meses del procedimiento endoscópico y 3 estenosis papilares. La mortalidad relacionada con la esfínteropapilotomía endoscópica fue del 1,64%. La esfinteropapilotomía endoscópica es el procedimiento de elección en pacientes colecistectomizados con litiasis de la vía biliar princiopañl y riesgo quirúrgico elevado, y en el drenaje precoz de la colangitis aguda obstructiva grave. Estaria indicada en colecistectomizados con litiasis de la vía biliar principal sin riesgo quirúrgico, colecistectomizados con litiasis cledociana, fracaso de la extracción instrumental con la técnica de Mondet-Mazzariello y en pacientes con vesícula in situ litiasis coledociana y riesgo quirúrgico elevado (AU)

Tratamiento endoscópico de la litiasis de la vía biliar principal / Endoscopic treatment of the lithiasis of the common bile duct

Se describe la experiencia de 10 años en el tratamiento de la vía biliar principal por esfinteropapilotomía endoscópica. En 501 pacientes se efectuaron 487 esinteropapilotomía endoscópicas satisfactorias (97,2%) y se fracasó en 14. Cuarenta y dos enfermos presentaron una complicación precoz vinculada al procedimiento (8,62%): hemorragía en 20 casos (4,1%), colangitis aguda en 11. Hubo 5 perforaciones, 2 pancreatitis agudas y en una pacientes la canastilla se atascó en la vía biliar. Se observaron 34 complicaciones alejadas: 31 litiasis residuales postesfinteropapilotomía endoscópica, 2 colecistitis agudas a los 14 y 20 meses del procedimiento endoscópico y 3 estenosis papilares. La mortalidad relacionada con la esfínteropapilotomía endoscópica fue del 1,64%. La esfinteropapilotomía endoscópica es el procedimiento de elección en pacientes colecistectomizados con litiasis de la vía biliar princiopañl y riesgo quirúrgico elevado, y en el drenaje precoz de la colangitis aguda obstructiva grave. Estaria indicada en colecistectomizados con litiasis de la vía biliar principal sin riesgo quirúrgico, colecistectomizados con litiasis cledociana, fracaso de la extracción instrumental con la técnica de Mondet-Mazzariello y en pacientes con vesícula in situ litiasis coledociana y riesgo quirúrgico elevado