Use of Simethicone After Capsule Ingestion and Its Impact on the Quality of Small Bowel Video Capsule Endoscopy: A Pilot Study.

Background Small bowel capsule endoscopy is a tool to visualize the small bowel (SB) for conditions such as obscure bleeding. Various studies have been performed to compare various bowel preparation regimens in terms of small bowel transit time (SBTT), small bowel visualization quality (SBVQ), and diagnostic yield (DY). Literature suggests that using polyethylene glycol (PEG) prep is significantly better compared to clear liquid and overnight fast in terms of SBVQ and DY. Other investigators have tried to assess the efficacy of adding simethicone to the bowel preparation regimen which seems to improve SBVQ. However, no studies have been done to assess the results of simethicone ingestion after capsule swallowing. We intend to give patients simethicone one hour after capsule ingestion for two consecutive hours and compare results for SBVQ pre-and post-ingestion groups. The objective of this study is to compare the effect of simethicone on SBVQ in pre- and post-capsule ingestion groups. Methodology This prospective, randomized controlled trial included patients who were scheduled for outpatient capsule endoscopy at Albany Medical Center (AMC) Endoscopy Suite. Patients were divided into the control group, group 1, and the treatment group (group 2). The control group followed the standard AMC pre-capsule protocol that included PEG 238 g the evening prior. Group 1 included patients who received 3 mL of simethicone (20 mg/0.3 mL) 20 minutes prior to ingesting the capsule. The treatment group (group 2) included patients who ingested simethicone 3 mL 20 minutes prior to capsule swallowing, 3 mL after one hour, and 1.5 mL after another hour, totaling 7.5 mL of simethicone. Data regarding SBVQ for every patient were evaluated as an individual zone score from 1-3 points, each in proximal, middle, and distal SB based on the SBTT. A cumulative score of 3-9 was given after adding the three zones. These scores were derived using the Boston Bowel Preparation Scale. Data analysis was done using Microsoft Excel software. Results There were six patients in the control group, eight in group 1, and eight in the treatment group (group 2). Proximal, middle, and distal SB did not show any significant difference between their SBVQ scores. Moreover, the total combined score also showed no statistical difference in the SBVQ score. Conclusions There were no statistically significant differences in the SBVQ neither while looking at the cumulative score nor individual segmental score of the entire SB. However, this is only a pilot project with a small number of subjects and results may differ in future studies with increased power.

The impact of primary tumor sidedness on survival in early-onset colorectal cancer by stage: A National Veterans Affairs retrospective analysis.

BACKGROUND: The incidence of early-onset colorectal cancer (EOCRC) is rising. Left-sided colorectal cancer (LCC) is associated with better survival compared to right-sided colon cancer (RCC) in metastatic disease. NCCN guidelines recommend the addition of EGFR inhibitors to KRAS/NRAS WT metastatic CRC originating from the left only. Whether laterality impacts survival in locoregional disease and EOCRC is of interest. METHODS: 65,940 CRC cases from the National VA Cancer Cube Registry (2001-2015) were studied. EOCRC (2096 cases) was defined as CRC diagnosed at <50 years. Using ICD codes, RCC was defined from the cecum to the hepatic flexure (C18.0-C18.3), and LCC from the splenic flexure to the rectum (C18.5-18.7; C19 and C20). RESULTS: EOCRC is more likely to originate from the left side (66.65% LCC in EOCRC vs. 58.77% in CRC). Overall, LCC has better 5-year Overall Survival (OS) than RCC in stages I (61.67% vs. 58.01%) and III (46.1% vs. 42.1%) and better 1-year OS in stage IV (57.79% vs. 49.49%). Stage II RCC has better 5-year OS than LCC (53.39% vs. 49.28%). In EOCRC, there is no statistically significant difference between LCC and RCC in stages I-III. Stage IV EOCRC patients with LCC and RCC have a 1-year OS of 73.23% and 59.84%, respectively. CONCLUSION: In EOCRC, LCC is associated with better OS than RCC only stage IV. In the overall population, LCC is associated with better OS in all stages except stage II. The better prognosis of stage II RCC might be due to the high incidence of mismatch repair deficient tumors in this subpopulation.

The Value of Family History in Colorectal Screening Decisions for Oldest Old Geriatric Populations.

INTRODUCTION: Colorectal cancer (CRC) is the second most common form of cancer affecting both men and women. Extensive screening guidelines have been developed to help reduce the incidence of disease. Currently, United States Preventative Service Task Force guidelines recommend against routine screening in those 85 years and older. However, octogenarians and nonagenarians continue to be screened for CRC with no consensus on indications. The aim of this study is to examine family history of CRC as a risk factor and clinical indication for providing screening colonoscopies to the "oldest old" geriatric population, defined as aged 80 years and above. METHODS: We conducted a retrospective review of a Veterans' Health Administration database to identify male veterans aged 80 years and older who underwent screening colonoscopy. Subsequently, we examined those who tested positive for CRC with a family history of CRC. RESULTS: Of the 458,224 patients who are 80 years and older in the Veterans Affairs (VA) database, 17.8% underwent a screening colonoscopy; 11.42% of these individuals were further diagnosed with CRC; and 8.89% of those with diagnosed CRC had a documented family history of CRC. CONCLUSION: Family history should not be used as an inclusionary criterion for CRC screening in the 80 years and above age group as the rate of CRC in these patients with a family history of CRC is significantly lower than that in the younger age groups with a family history of CRC.

Treatment and survival rates of stage IV pancreatic cancer at VA hospitals: a nation-wide study.

BACKGROUND: Metastatic pancreatic cancer (MPC) is associated with an extremely high mortality. Current NCCN guidelines recommend systemic therapy, as it is superior to best supportive care. Undertreatment of MPC continues to be an issue. Recent treatment and survival data of MPC in Veterans' Affairs' (VA) hospitals have not been published. The relationship between MPC treatment and survival and the American College of Surgeons' (ACS) Committee on Cancer (CoC) accreditation in VA hospitals has not been studied. METHODS: Nationwide data from the National Veterans Affairs Cancer Cube Registry was analyzed. In total, 6,775 patients were diagnosed with MPC between 2000 and 2014. CoC accreditation of each VA hospital was obtained using the ACS website. RESULTS: MPC constitutes 52.31% of all pancreatic cancer diagnosed (6,775/12,951 cases). The near totality was men (97.44%). The above 70 years age group and the 60-70 years age group were the most common ages at diagnosis with 39.39% and 38.02% respectively. The proportion of early-onset pancreatic cancer (EOPC) was 2.84%. When compared to all stages of pancreatic cancer, stage IV pancreatic cancer had a lower proportion of cancer originating from the head of the pancreas (39.33% versus 50.63%) and more originating from the tail (17.99% versus 13.39%). Tumors originating from head of the pancreas are more likely to cause biliary symptoms and thus are more likely to be caught at an earlier stage. Overall, treatment rate in the VA at the national level with first-line chemotherapy was 37.61%. The rate of treatment over the years has increased in a linear fashion from 33.01% in 2000 to 41.95% in 2014. This has corresponded with an increase of 1-5 years survival of 9.29% in 2000 to 22.99% in 2014 and 5-10 years survival from 0.96% in 2000 to 6.00% in 2012. Treatment rates in CoC-accredited and non-CoC accredited VA hospitals were similar (38.94% and 38.12%, respectively). Survival rates in CoC-accredited and non-COC accredited VAs were similar with a 1-5 years survival rate of 8.89% and 8.57%, respectively. CONCLUSIONS: Treatment and survival of MPC have risen significantly in the past decade at VA hospitals. CoC accreditation is not associated with a change in treatment or survival rates.

Colonoscopy and colorectal cancer rates among octogenarians and nonagenarians: nationwide study of US veterans.

BACKGROUND: According to Surveillance, Epidemiology and End Results (SEER) database, colorectal cancer (CRC) is the fourth most common type of cancer and second highest in cancer-related death after lung cancer. The SEER database is geographically limited, currently present in only 10-12 states. Though this gives a good approximation about the overall direction of CRC incidence and prevalence, we need more nationwide data to compare numbers. Furthermore, colonoscopies and CRC rates in the Veterans Affair (VA) geriatric population have not been studied. OBJECTIVES AND METHODS: Our aim was to study the rate of colonoscopies and CRC in octogenarians and nonagenarians and to find the prevalence of CRC in this population. The goal was to obtain data in this subset of patients in order to further expand CRC screening guidelines. A retrospective data analysis was performed consisting of US male veterans who underwent colonoscopy in the VA Health Care System from 2000 to 2015. RESULTS AND CONCLUSION: A total of 458,224 patients aged ≥80 years were identified from the database between years 2000 and 2015. This was divided into three groups of age 80-84 years (89,621 patients), 85-90 years (248,155 patients), and >90 years (120,448 patients). A total of 81,946 patients underwent colonoscopies of which 9,365 were diagnosed with CRC. There was a statistically significant linear increase in rate of colonoscopies with increase in age suggesting that these veterans who end up living to a higher age eventually get a colonoscopy for one reason or the other. The drop in CRC percentage and prevalence observed in age group 85-90 years is statistically different when compared to that in 80-84 years and >90 years groups; however, its clinical significance remains to be elucidated.

Staging and survival of colorectal cancer (CRC) in octogenarians: Nationwide Study of US Veterans.

BACKGROUND: The US Preventive Services Task Force of Colorectal Cancer (USPSTF) recommends against continuing screening for colorectal cancer (CRC) past 75 years in adequately screened individuals. Survival and staging data for CRC that compares elderly vs. younger populations has not been published. This study aims to compare staging (0-4) of CRC in groups of 60-69, 70-79 and 80-89-year-old; also, to compare surgical and no treatment (i.e., no surgery) survival outcomes (5-10 years) in these age groups. METHODS: Male veterans within groups 60-69, 70-79 and 80-89 years of age who were diagnosed with CRC between 2000 and 2015 were selected from Veterans affairs national cancer cube registry. RESULTS: Their staging, surgery or no treatment, and 5-10 years survival data was obtained from the cancer cube. Surgical and survival data was obtained only for stage 0-2 as surgery is currently the standard of treatment for these stages. CONCLUSIONS: Highest number of CRC cases diagnosed across each age group was stage 1 with stage 2 being second. In surgical treatment group the survival was statistical different for 80-89 age group as compared to 60-69 (34.4%) and 70-79 (30.86%) although octogenarians did have a surprisingly high mean of 25.45%. The 5-10-year survival data for no treatment group (i.e., no surgery) was very poor.

Successful stent-in-stent dilatation of the common bile duct through a duodenal prosthesis, a novel technique for malignant obstruction: A case report and review of literature.

For patients suffering from both biliary and duodenal obstruction, endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is the treatment of choice. ERCP through an already existing duodenal prosthesis is an uncommon procedure and furthermore no studies have reported installing a covered metal stent onto an already existing bare metal stent in the common bile duct (CBD). We describe a rare case of a stent-in-stent dilatation of the CBD through an already existing self-expanding metal stent in the second part of duodenum for the patient presenting with jaundice in setting of biliary and duodenal obstruction from pancreatic adenocarcinoma. The biliary obstruction was relieved with a decrease in bilirubin levels post-stenting.