Application of validated bleeding risk scores for atrial fibrillation in obscure gastrointestinal bleeding patients increases videocapsule endoscopy's diagnostic yield: a retrospective monocentric study.

BACKGROUND: Videocapsule endoscopy (VCE) is considered the gold standard for overt and obscure gastrointestinal bleeding (OGIB), after negative upper and lower endoscopy. Nonetheless, VCE's diagnostic yield is suboptimal, and it represents a costly, time-consuming, and often not easily available technique. In order to evaluate bleeding risk in patients with atrial fibrillation, several scoring systems have been proposed, but their utilization outside the original clinical setting has rarely been explored. The aim of the study is to evaluate potential role of bleeding risk scoring systems in predicting the occurrence of positive findings at VCE examination, and therefore in increasing VCE diagnostic yield. METHODS: Data from consecutive patients undergoing VCE between April 2015 and June 2020 were retrospectively retrieved, and clinical and demographic characteristics were collected. HAS-BLED, ATRIA, and ORBIT scores were calculated, and patients were considered at low or high risk of bleeding accordingly. Discriminative ability of the scores for positive VCE findings has been evaluated by area under receiver operator characteristic curve (AUC) calculation. Diagnostic yield of scores in high- and low-risk patients was calculated. RESULTS: A total of 413 patients underwent VCE examination, among which 368 (89%) for OGIB. Positive findings were observed in 246 patients (67%), with angiodysplasias being the most frequent lesion (92%). The three scores displayed similar consistent discriminative ability for positive VCE findings (mean AUC = 0.69), and identified high-risk group of patients in which VCE has a higher diagnostic yield. CONCLUSIONS: In the present retrospective study, bleeding scores accurately discriminated patients with higher probability of positive findings at VCE examination. Bleeding scores utilization may help in the management of patients with OGIB, with a potential consistent resource optimization and cost-saving.

[Endoscopic-laparoscopic treatment of neoplastic occlusion of the left colon]. / Il trattamento endoscopico laparoscopico dell'occluslone neoplastica del colon sinistro.

About a third of patients with colorectal carcinoma have acute colonic obstruction requiring emergency surgery. The surgical options are: intraoperative lavage and resection of the colonic segment involved with primary anastomosis; subtotal colectomy with primary anastomosis; colostomy followed by resection; and resection of the colonic segment involved with an end colostomy (Hartman's procedure) requiring a second operation to reconstruct the colon. These procedures present risks and are associated with a poor quality of life. Endoscopic colonic stent insertion effectively decompresses the obstructed colon allowing bowel preparation and elective resection. In this article we present 2 cases successfully treated with the use of stents followed by a laparoscopic resection. We also describe technical details concerning the endoscopy and laparoscopy procedure, discuss the advantages of this treatment and present a review of the literature. One patient underwent a left hemicolectomy; while the other was treated with splenic flexure resection. No complications occurred after surgery. Histological staging revealed a pT3 pNO pMx G2 and a pT4 pN1 pM1 G2 adenocarcinoma, respectively. This initial experience shows that endoscopic colonic stent insertion can effectively resolve the neoplastic obstruction, allowing safe elective surgery. The use of stents does not prevent a laparoscopic approach.

Preoperative colonoscopy after self-expandable metallic stent placement in patients with acute neoplastic colon obstruction.

BACKGROUND: In patients with colorectal cancer, a preoperative colonoscopy is recommended to exclude synchronous lesions. Unfortunately, between 7% and 29% of patients with colorectal cancer present with acute colonic obstruction, making complete colonoscopy impossible. OBJECTIVE: The aim of our study was to evaluate the feasibility of a preoperative colonoscopy after effective stent placement in patients with acute neoplastic obstruction. DESIGN: Single-center prospective study. SETTING: All examinations were carried out at a tertiary referral center with 24-hour emergency endoscopy service. PATIENTS: Fifty-seven patients with acute neoplastic colon obstruction. INTERVENTIONS: Patients who recovered from an acute colon obstruction by an effective stent placement and who had a resectable cancer underwent a preoperative colonoscopy. MAIN OUTCOME MEASUREMENTS: Patients with a resectable cancer, complete preoperative colonoscopies, and synchronous lesions rates. RESULTS: Self-expandable metallic stents (SEMS) were placed in 50 of 57 patients (87.8%). Thirty-one of 50 patients had a resectable cancer (62%), and a complete preoperative colonoscopy was possible in 29 of 31 patients (93.4%). A synchronous cancer was detected in 3 patients (9.6%), changing the surgical plan. LIMITATIONS: Seven patients in whom the SEMS placement (12.2%) was unsuccessful underwent an urgent surgical intervention. Nineteen of 50 patients who had stent placement were not eligible for our study because of unresectable cancer. CONCLUSIONS: Our study indicates that it is feasible in a majority of patients to perform full preoperative colonoscopy after relief of acute colonic obstruction with SEMS before surgical resection.

Routine ileoscopy at colonoscopy: a prospective evaluation of learning curve and skill-keeping line.

BACKGROUND: Ileoscopy is the criterion standard for mucosal lesions of terminal ileum but is performed in 5% of colonoscopy activity, and the need for training is undefined. OBJECTIVE: To assess the learning curve and skill-keeping line of ileoscopy. DESIGN: Prospective randomized study. SETTING: Single GI endoscopy unit. PATIENTS: Adult outpatients referred for colonoscopy. INTERVENTIONS: Patient randomization to ileocolonoscopy by trainees and seniors. MAIN OUTCOME MEASUREMENTS: Ileoscopy skill was divided into the following: ileocecal valve (ICV) intubation (success rate, time) and ileal exploration (length, time). Consecutive blocks of 10 procedures were used to calculate the learning curve and the skill-keeping line. Variables considered to influence ICV intubation were the following: endoscopist experience, ICV morphology, patient age, gender, body mass index, diverticular disease, and preceding abdominal/pelvic surgery. RESULTS: Learning curve showed that competency in ICV intubation (80% success rate) and ileal exploration (16 cm) was achieved after 50 procedures. The skill-keeping line showed that ileoscopy was easy (97% success rate), fast (1 minute), and well accepted up to 45 cm of the ileum. Thin-lipped and volcanic ICV are the most difficult and easiest to intubate, respectively. Crohn's disease and adenomas of the proximal edge of ICV were diagnosed in 2.2%. CONCLUSIONS: Training in ileoscopy is recommended to achieve competency, and endoscopists should consider practicing ICV intubation to maintain and increase their skill. Ileoscopy can be difficult when the ICV is thin lipped or single bulged, and easy when it has a volcanic morphology.