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610 Observation of Human Stomach by Using a Body-Friendly and Self-Propelling Capsule Endoscope
Abstracts
absorbed from the bowel lumen and prevents distention of abdomen and mitigates patient’s pain. Aims: It was compared the effects of CO2 and air insufflations on the intubation depth during single balloon enteroscopy (SBE) and post procedure pain. Patients and methods: It was a retrospective study. 147 procedures of single balloon enteroscopy were performed in 130 patients with suspected small bowel disease using CO2 insufflation in 65 procedures and air in 82. Enteroscopy Olympus SIF 180-Q / XSIF 180 JY and CO2 pump UCR were used. It was recorded the intubation depth using validate form and postprocedure pain immediately after SBE and 12 hours later (100 mm visual analog scale). Results: In 130 patients were performed 147 procedures of SBE with a mean small bowel intubation depth in the CO2 group significantly larger compared to the air group (219 ⫾ 92 vs 178 ⫾ 89 cm, p ⫽ 0.008). 95 procedures were performed by oral approach with a mean intubation depth significantly larger in the CO2 group of 236 ⫾ 73 vs. 199 ⫾ 87 cm in the air group (p ⫽ 0,035). It was used the anal approach in 52 SBE, the mean depth intubation was 183 ⫾ 118 in CO2 group and 141 ⫾ 81 cm in air group (p ⫽ 0.004). Patient’s pain was significantly reduced in the CO2 group at 1st and 12th hours after the examination. Patients with prior surgery did not experience pain post-procedure when used CO2 (n ⫽ 8) compared with those of the air insufflation group (n ⫽ 5), all of them had pain (p ⫽ 0.002). Complications were not reported. Conclusion: CO2 insufflation significantly improves intubation depth in SBE and reduces abdominal pain. Key words: single balloon enteroscopy (SBE), CO2 insufflations, small bowel (SB).
609 Endoscopic Management of Duodenal Neoplasms and Factors Leading to Incomplete Resection and Recurrence: Where Are We Now? Reem Z. Sharaiha1, Susana Gonzalez1, Christopher Ramos2, Amrita Sethi1, John M. Poneros1, Harold Frucht1, Peter D. Stevens1 1 Gastroenterology and Hepatology, Columbia Univerisity Medical Center - New York Presbyterian Hospital, New York, NY; 2Internal Medicine, Columbia University Medical Center, New York, NY Background: The incidence of sporadic duodenal adenomas is increasing and estimated at 0.1-0.3%. These lesions are being managed with endoscopic techniques over surgery. Given the risk of malignant progression, understanding factors associated with incomplete resection and recurrence is vital. We aimed to determine characteristics of duodenal neoplasms associated with incomplete resection and recurrence and to assess whether endoscopic management yielded results similar to surgery. Methods: A retrospective analysis of sporadic duodenal, peri-ampullary adenomas and adenocarcinomas in patients referred for endoscopic resection at our center between 2006-2010 was performed. Data was collected on patient demographics, clinical characteristics, histology, resection technique, recurrence and death. We defined incomplete resection as a positive biopsy result on subsequent endoscopy, and recurrence as detection of adenoma on a biopsy after a previously negative endoscopy. Logistic regression modeling was performed to analyze characteristics associated with recurrence. Results: Ninety-six patients presented with duodenal adenomas, 51% male and 75% caucasian. Median duration of follow-up was 16 months (IQR 7-56). EUS was done in 35% and 12 patients were unresectable and referred to surgery. Four of the 12 patients were metastatic and therefore excluded from the analysis. 84 patients had endoscopic resection, and 6 patients had advanced histology and referred for surgery. Thirty-two patients had subsequent endoscopic therapy for incomplete resection, with an average of 2.7 endoscopies (range 1-7). Fourteen had a recurrence after a negative biopsy. Two patients had adenomas at a secondary site. While 11.4% had bleeding, there were no cases of perforations or pancreatitis. There were 11.3% deaths and predictors included African American race, advanced histology, lesion size and surgery. Surgery had a higher morbidity, (P⫽0.011), but patients were more likely to have advanced histology. There was no difference in incomplete resection or recurrence when comparing endoscopic to surgical therapy. (P value⫽ 0.852, 0.299 respectively).Univariate analysis demonstrated that elevated BMI, involvement of layers 3&4, and advanced histology were associated with incomplete resection and repeat procedures. (P⬍0.05) Multivariable logistic regression elevated BMI, advanced EUS findings and size were all associated with incomplete resection ( P⬍0.05). Race, age, or resection method were not significant after adjustment for potential confounders. Conclusions: BMI, size, advanced histology are prognostic markers for incomplete resection and recurrence after endoscopic resection of duodenal neoplasms. Compared to surgery, endoscopic resection has less morbidity and outcomes are comparable, therefore endoscopic resection should be attempted with amenable lesions.
610 Observation of Human Stomach by Using a Body-Friendly and Self-Propelling Capsule Endoscope Naotake Ohtsuka1, Eiji Umegaki2, Yasunori Shindo1, Kenshiro Uesugi1, Hironori Nishihara1, Takanori Kuramoto2, Yuichi Kojima2, Mitsuyuki Murano2, Kazuhide Higuchi2 1 Department of Mechanical and Systems Engineering, Ryukoku University, Ohtsu, Japan; 22nd Department of Internal Medicine, Osaka Medical College, Takatsuki, Japan Background: Unlike the tube endoscope, a capsule endoscope (CE) occasionally does not allow examiners to observe a lesion at the desired position and direction in real time. To overcome this disadvantage, we had previously developed a self-propelling capsule endoscope (SPCE), which is propelled in the digestive tract under the influence of the magnetic field, and this is used for examination of the digestive tract in real time. Then, we had reported that the SPCE was used in vivo to observe the stomach of a dog under sedation (Morita et al., DDW 2009) and could be propelled in resected large and small intestines (Morita et al., DDW 2010). This study shows that we have improved the SPCE so that it can be swallowed easily and propelled safely into the stomach of a human without a float and gastric examination in vivo. Method: The SPCE that we have developed has a fin with a small magnet attached at the end of the CE and is propelled by a fluctuating magnetic field remotely, and the moving velocity and direction are controlled freely by adjusting the wave form of the electric current running in the magnetic coils. In our previous examination, the SPCE had a foamed polystyrene float, which is attached at the outer side of a CE so that it would float on water, and it was inserted into a sedated dog’s stomach by gastroendoscopy. However, for easy swallowing of SPCE, we have removed the float from the SPCE and redesigned it (Mermaid, MM1) such that it could move at the bottom of the water. The MM1 has a total size of 12 ⫻ 45 mm and has a flexible silicone fin, which contains a magnet. Before swallowing the MM1, 500 ml of water had to be consumed by a volunteer. The fornix and gastric body were observed at the left decubitus position, the gastric body and gastric angle at the decubitus dorsal position, and the antrum at the right decubitus position. Results: (1) The SPCE (MM1) could be swallowed easily and safely without sedation, and it passed through the esophagus and cardia in a short time. (2) The MM1 could propel by itself under water in the stomach without injuring the gastric wall, and the moving direction and velocity were controlled remotely. (3) Each gastric position could be observed, and the images were obtained and monitored in real time. Conclusion: The human stomach was examined using an improved SPCE—MM1. Our study suggests that SPCE would soon be applied in the clinical diagnosis of the whole digestive tract.
670 Adenoma Detection With Cap-Assisted Colonoscopy Versus Regular Colonoscopy: A Randomized Controlled Trial Thomas R. De Wijkerslooth1, Esther M. Stoop2, Patrick M. Bossuyt3, Elisabeth M. Mathus-Vliegen1, Jan Dees2, Kristien M. Tytgat1, Monique Van Leerdam2, Paul Fockens1, Ernst J. Kuipers2,4, Evelien Dekker1 1 Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands; 2Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Netherlands; 3Clinical Epidemiology and Biostatistics, Academic Medical Center, Amsterdam, Netherlands; 4 Internal Medicine, Erasmus Medical Center, Rotterdam, Netherlands Background: Colonoscopy is widely accepted as the gold standard for detection of colorectal neoplasia, but it is also known to be an imperfect test. Adenoma detection miss-rates were reported in tandem colonoscopy studies to be as high as 22% for all size adenomas. Performing colonoscopy with a transparent plastic cap attached to the tip of the colonoscope (cap-assisted colonoscopy) may enhance adenoma detection due to improved visualization of the mucosal surface. Aim: To compare adenoma detection with cap-assisted colonoscopy (CAC) to regular colonoscopy (RC). Secondary outcomes were total number of detected adenomas per patient, cecal intubation time and rate. Methods: Data were collected in the Colonoscopy or Colonography for Screening (COCOS) study, a multicenter randomized controlled trial. Asymptomatic individuals (50-75 years) who participated in the primary colonoscopy arm of the colorectal cancer screening program were invited to participate. Consenting screenees were 1:1 randomized to either CAC or RC. All colonoscopies were done by experienced colonoscopists (ⱖ 1000 colonoscopies) and trained in CAC. The quality of bowel prep was assessed by the validated Ottawa scale (0-14). The primary outcome measure was adenoma detection, defined as the proportion of patients with at least one adenoma. Total number of adenomas per patient was defined as the total number of detected adenomas in each group divided by the number of allocated subjects. Results: A total of 1227 patients (male 52%, median age 60) were allocated to CAC (N⫽607) or RC (N⫽620). Cecal intubation rate was similar in both groups (99% vs. 98%; p⫽0.37). Cecal intubation time was significantly lower in CAC (8.0 vs. 9.4 minutes; p⬍0.001). Withdrawal time (12.3 vs. 12.4 minutes; p⫽0.85) and quality of the bowel prep (5.7 ⫾ 3.1 vs. 5.5 ⫾ 3.2;
AB140 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
absorbed from the bowel lumen and prevents distention of abdomen and mitigates patient’s pain. Aims: It was compared the effects of CO2 and air insufflations on the intubation depth during single balloon enteroscopy (SBE) and post procedure pain. Patients and methods: It was a retrospective study. 147 procedures of single balloon enteroscopy were performed in 130 patients with suspected small bowel disease using CO2 insufflation in 65 procedures and air in 82. Enteroscopy Olympus SIF 180-Q / XSIF 180 JY and CO2 pump UCR were used. It was recorded the intubation depth using validate form and postprocedure pain immediately after SBE and 12 hours later (100 mm visual analog scale). Results: In 130 patients were performed 147 procedures of SBE with a mean small bowel intubation depth in the CO2 group significantly larger compared to the air group (219 ⫾ 92 vs 178 ⫾ 89 cm, p ⫽ 0.008). 95 procedures were performed by oral approach with a mean intubation depth significantly larger in the CO2 group of 236 ⫾ 73 vs. 199 ⫾ 87 cm in the air group (p ⫽ 0,035). It was used the anal approach in 52 SBE, the mean depth intubation was 183 ⫾ 118 in CO2 group and 141 ⫾ 81 cm in air group (p ⫽ 0.004). Patient’s pain was significantly reduced in the CO2 group at 1st and 12th hours after the examination. Patients with prior surgery did not experience pain post-procedure when used CO2 (n ⫽ 8) compared with those of the air insufflation group (n ⫽ 5), all of them had pain (p ⫽ 0.002). Complications were not reported. Conclusion: CO2 insufflation significantly improves intubation depth in SBE and reduces abdominal pain. Key words: single balloon enteroscopy (SBE), CO2 insufflations, small bowel (SB).
609 Endoscopic Management of Duodenal Neoplasms and Factors Leading to Incomplete Resection and Recurrence: Where Are We Now? Reem Z. Sharaiha1, Susana Gonzalez1, Christopher Ramos2, Amrita Sethi1, John M. Poneros1, Harold Frucht1, Peter D. Stevens1 1 Gastroenterology and Hepatology, Columbia Univerisity Medical Center - New York Presbyterian Hospital, New York, NY; 2Internal Medicine, Columbia University Medical Center, New York, NY Background: The incidence of sporadic duodenal adenomas is increasing and estimated at 0.1-0.3%. These lesions are being managed with endoscopic techniques over surgery. Given the risk of malignant progression, understanding factors associated with incomplete resection and recurrence is vital. We aimed to determine characteristics of duodenal neoplasms associated with incomplete resection and recurrence and to assess whether endoscopic management yielded results similar to surgery. Methods: A retrospective analysis of sporadic duodenal, peri-ampullary adenomas and adenocarcinomas in patients referred for endoscopic resection at our center between 2006-2010 was performed. Data was collected on patient demographics, clinical characteristics, histology, resection technique, recurrence and death. We defined incomplete resection as a positive biopsy result on subsequent endoscopy, and recurrence as detection of adenoma on a biopsy after a previously negative endoscopy. Logistic regression modeling was performed to analyze characteristics associated with recurrence. Results: Ninety-six patients presented with duodenal adenomas, 51% male and 75% caucasian. Median duration of follow-up was 16 months (IQR 7-56). EUS was done in 35% and 12 patients were unresectable and referred to surgery. Four of the 12 patients were metastatic and therefore excluded from the analysis. 84 patients had endoscopic resection, and 6 patients had advanced histology and referred for surgery. Thirty-two patients had subsequent endoscopic therapy for incomplete resection, with an average of 2.7 endoscopies (range 1-7). Fourteen had a recurrence after a negative biopsy. Two patients had adenomas at a secondary site. While 11.4% had bleeding, there were no cases of perforations or pancreatitis. There were 11.3% deaths and predictors included African American race, advanced histology, lesion size and surgery. Surgery had a higher morbidity, (P⫽0.011), but patients were more likely to have advanced histology. There was no difference in incomplete resection or recurrence when comparing endoscopic to surgical therapy. (P value⫽ 0.852, 0.299 respectively).Univariate analysis demonstrated that elevated BMI, involvement of layers 3&4, and advanced histology were associated with incomplete resection and repeat procedures. (P⬍0.05) Multivariable logistic regression elevated BMI, advanced EUS findings and size were all associated with incomplete resection ( P⬍0.05). Race, age, or resection method were not significant after adjustment for potential confounders. Conclusions: BMI, size, advanced histology are prognostic markers for incomplete resection and recurrence after endoscopic resection of duodenal neoplasms. Compared to surgery, endoscopic resection has less morbidity and outcomes are comparable, therefore endoscopic resection should be attempted with amenable lesions.
610 Observation of Human Stomach by Using a Body-Friendly and Self-Propelling Capsule Endoscope Naotake Ohtsuka1, Eiji Umegaki2, Yasunori Shindo1, Kenshiro Uesugi1, Hironori Nishihara1, Takanori Kuramoto2, Yuichi Kojima2, Mitsuyuki Murano2, Kazuhide Higuchi2 1 Department of Mechanical and Systems Engineering, Ryukoku University, Ohtsu, Japan; 22nd Department of Internal Medicine, Osaka Medical College, Takatsuki, Japan Background: Unlike the tube endoscope, a capsule endoscope (CE) occasionally does not allow examiners to observe a lesion at the desired position and direction in real time. To overcome this disadvantage, we had previously developed a self-propelling capsule endoscope (SPCE), which is propelled in the digestive tract under the influence of the magnetic field, and this is used for examination of the digestive tract in real time. Then, we had reported that the SPCE was used in vivo to observe the stomach of a dog under sedation (Morita et al., DDW 2009) and could be propelled in resected large and small intestines (Morita et al., DDW 2010). This study shows that we have improved the SPCE so that it can be swallowed easily and propelled safely into the stomach of a human without a float and gastric examination in vivo. Method: The SPCE that we have developed has a fin with a small magnet attached at the end of the CE and is propelled by a fluctuating magnetic field remotely, and the moving velocity and direction are controlled freely by adjusting the wave form of the electric current running in the magnetic coils. In our previous examination, the SPCE had a foamed polystyrene float, which is attached at the outer side of a CE so that it would float on water, and it was inserted into a sedated dog’s stomach by gastroendoscopy. However, for easy swallowing of SPCE, we have removed the float from the SPCE and redesigned it (Mermaid, MM1) such that it could move at the bottom of the water. The MM1 has a total size of 12 ⫻ 45 mm and has a flexible silicone fin, which contains a magnet. Before swallowing the MM1, 500 ml of water had to be consumed by a volunteer. The fornix and gastric body were observed at the left decubitus position, the gastric body and gastric angle at the decubitus dorsal position, and the antrum at the right decubitus position. Results: (1) The SPCE (MM1) could be swallowed easily and safely without sedation, and it passed through the esophagus and cardia in a short time. (2) The MM1 could propel by itself under water in the stomach without injuring the gastric wall, and the moving direction and velocity were controlled remotely. (3) Each gastric position could be observed, and the images were obtained and monitored in real time. Conclusion: The human stomach was examined using an improved SPCE—MM1. Our study suggests that SPCE would soon be applied in the clinical diagnosis of the whole digestive tract.
670 Adenoma Detection With Cap-Assisted Colonoscopy Versus Regular Colonoscopy: A Randomized Controlled Trial Thomas R. De Wijkerslooth1, Esther M. Stoop2, Patrick M. Bossuyt3, Elisabeth M. Mathus-Vliegen1, Jan Dees2, Kristien M. Tytgat1, Monique Van Leerdam2, Paul Fockens1, Ernst J. Kuipers2,4, Evelien Dekker1 1 Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands; 2Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Netherlands; 3Clinical Epidemiology and Biostatistics, Academic Medical Center, Amsterdam, Netherlands; 4 Internal Medicine, Erasmus Medical Center, Rotterdam, Netherlands Background: Colonoscopy is widely accepted as the gold standard for detection of colorectal neoplasia, but it is also known to be an imperfect test. Adenoma detection miss-rates were reported in tandem colonoscopy studies to be as high as 22% for all size adenomas. Performing colonoscopy with a transparent plastic cap attached to the tip of the colonoscope (cap-assisted colonoscopy) may enhance adenoma detection due to improved visualization of the mucosal surface. Aim: To compare adenoma detection with cap-assisted colonoscopy (CAC) to regular colonoscopy (RC). Secondary outcomes were total number of detected adenomas per patient, cecal intubation time and rate. Methods: Data were collected in the Colonoscopy or Colonography for Screening (COCOS) study, a multicenter randomized controlled trial. Asymptomatic individuals (50-75 years) who participated in the primary colonoscopy arm of the colorectal cancer screening program were invited to participate. Consenting screenees were 1:1 randomized to either CAC or RC. All colonoscopies were done by experienced colonoscopists (ⱖ 1000 colonoscopies) and trained in CAC. The quality of bowel prep was assessed by the validated Ottawa scale (0-14). The primary outcome measure was adenoma detection, defined as the proportion of patients with at least one adenoma. Total number of adenomas per patient was defined as the total number of detected adenomas in each group divided by the number of allocated subjects. Results: A total of 1227 patients (male 52%, median age 60) were allocated to CAC (N⫽607) or RC (N⫽620). Cecal intubation rate was similar in both groups (99% vs. 98%; p⫽0.37). Cecal intubation time was significantly lower in CAC (8.0 vs. 9.4 minutes; p⬍0.001). Withdrawal time (12.3 vs. 12.4 minutes; p⫽0.85) and quality of the bowel prep (5.7 ⫾ 3.1 vs. 5.5 ⫾ 3.2;
AB140 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org