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Double Balloon Colonoscopy: First Experience with a Dedicated Endoscope-Overtube System in Patients with Previous Difficult and Incomplete Colonoscopy
Abstracts
lesion raised histologic diagnostic yield. Thus, our study suggests colonoscopy might be more helpful than sigmoidoscopy to diagnose GVHD in patients with aHSCT. Endoscopic findings Colonoscopy Sigmoidoscopy Histologic confirmation
Normal (%)
MpD(%)
) Up (%)
4 (12.1) 10 (31.3) 1 (7)
13 (39.4) 15 (46.9) 17 (61)
16 (48.5) 7 (21.9) 20 (87)
þ Mucosal change predominant)Ulcer predominant
T1404 Double Balloon Colonoscopy: First Experience with a Dedicated Endoscope-Overtube System in Patients with Previous Difficult and Incomplete Colonoscopy Michel Delvaux, Muriel Frederic, Isaac Fassler, Gerard Gay The technique of double balloon endoscopy developed for retrograde enteroscopy has been used to perform colonoscopy in patients with difficult progression of the endoscope. A new endoscopic system, the double balloon colonoscope (DBC) has recently been developed (EC-450B15 Fujinon Optical, Saitama, Japan). The aim of this study was to evaluate the ability of DBC to achieve a complete colonoscopy in patients in whom it previously failed in order to determine indications and refine technical stipulations. Patients and Method: From January 2007 to June 2008, a DBC was proposed to all patients having undergone an incomplete colonoscopy, excluding failures due to poor bowel cleansing. After cleansing with 22L PEG, colonoscopy was performed under general anaesthesia with Propofol delivered by an anaesthesiologist, with an EC-450B15, 182 cm long, thin colonoscope (diameter 9.4 mm), an operating channel of 2.8 mm and a view angle of 140 . The overtube is 101cm long and 13.2 mm in diameter. The distal end of both the endoscope and the overtube are equipped with a latex balloon that can be inflated/deflated under control of a barostatic pump. Completeness of the colonoscopy was defined as the possibility to maintain the endoscope in a stable position in the caecum. Indication, reason for failure of previous colonoscopy, time to reach the caecum, need for fluoroscopic control of the progression and adverse events were prospectively recorded. Results: 81 patients (57 men, 24 women, mean age 56 16 years) a first colonoscopy attempt failed in our endoscopy unit (nZ44) or another one (nZ37) because of post-surgical peritoneal adhesions (n Z 4), a fixed colonic angle (nZ42), a dolichocolon (nZ30), a tight diverticulosis (nZ5). DBC was complete in 79 patients (97.5%), reaching the caecum in 49, the terminal ileum in 23 and the ileo-colonic anastomosis in 7. The DBC failed to reach the caecum and was limited to the transverse colon in 2 patients: one acromegalic female patient and one male patient with an adult Hirshprung’s disease. The mean duration of the DBC was 2418 min, similar to the mean duration of a classical colonoscopy in our unit. A relevant diagnosis was obtained in 58 patients (74.4%). All needed biopsies could be performed and a polypectomy was performed in 16 patients. No complication was observed. Conclusion: DBC enables full colonic examination in patients with previous difficult colonoscopy. The procedure is safe, can be performed by an endoscopist with the help of a trained endoscopy nurse and fluoroscopic control of the progression is necessary only in the most difficult cases.
T1405 Endoscopic Management of Massive Acute Lower Gastrointestinal Bleeding Paulo Correa, Marcelo Averbach, Jose Paccos, Giulio F. Rossini, Oswaldo W. Marques, Pedro Popoutchi Background: The management of moderate or massive acute lower intestinal bleeding (ALIB) is not well established. Although there are several strategies for the diagnosis and treatment of patients with ALIB we believe that colonoscopy within 6 hours of its presentation can be performed safely with a high rate of success in localizing and often treating the specific cause of bleeding. Aim: To assess the role of early colonoscopy as the primary method of evaluation in patients with ALIB. Methods: From January 1986 to October 2008, 29209 colonoscopies were performed in the endoscopy unit of Sı´rio Libaneˆs Hospital, Sao Paulo. Two hundred and thirty (0,79%) were urgent due to ALIB. After clinical stabilization the patients received an anterograde bowel preparation and the exams were done always under sedation. Results: Definitive diagnosis was accurate in 147 patients (64%). Diverticula (16 patients), Post-Polypectomy (16) and Angiodysplasia (14) were the predominant sources of bleeding. In 69 patients (49%) a specific therapeutic intervention was done, including fulguration (13 patients), endoscopic injection of sclerosing agents (34), APC (10), metallic endoscopic clips (10) and elastic band ligation (2). Control of active hemorrhage was achieved endoscopically in 100% of these patients. Conclusions: These data shows the importance of early colonoscopy in the management of patients with acute lower intestinal bleeding making possible its diagnosis and treatment.
AB288 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
T1406 Endoscopic Mucosal Resection Appears Equally Effective, But Is Associated with Less Morbidity Than Transanal Endoscopic Microsurgery for the Treatment of Large Rectal Adenomas Frank J. Van Den Broek, Joyce Van Schooten, Willem Bemelman, Eelco J. De Graaf, Paul Fockens, Evelien Dekker Introduction: Large rectal adenomas are currently being treated by either transanal endoscopic microsurgery (TEM) or piecemeal endoscopic mucosal resection (EMR). EMR is likely to be associated with lower morbidity, although this potential advantage may become irrelevant if these treatments are not equally effective. We conducted a retrospective study to compare the safety and effectiveness of TEM vs. EMR for the treatment of large rectal adenomas. Methods: Data were collected from patients with a preoperative diagnosis of a large rectal adenoma (O2 cm) who underwent TEM or EMR in 8 Dutch hospitals from January 2004-December 2007. Patient and procedure related characteristics, as well as complications and recurrences were registered. Since EMR may require several attempts to achieve complete removal of adenomas, two recurrence rates were defined: early and late recurrences (including and not including remnant adenomas successfully re-treated during the first control endoscopy). Results: In total, 248 patients were treated by TEM and 51 by EMR (144 male; mean 67 yrs). With respect to sex and age, there were no differences between TEM and EMR; however, adenomas treated by EMR were located higher in the rectum (mean 9.4 vs. 6.7cm ab ano) and were smaller in size (median 30 vs. 40 mm; p!0.001). Histological evaluation of the resection specimen revealed unexpected invasive cancer in 11.3% after TEM and 3.9% after EMR (pZ0.278). Intra-operative perforation occurred in 29 TEM procedures (12%) and in none of the EMR procedures (pZ0.007). Postoperative complications occurred in 69 patients (28%; major 8.5%) after TEM and in 5 patients (9.8%; major 0%) after EMR (pZ0.007). Complications needing operative intervention occurred in 16 (6.5%) patients after TEM versus no patients after EMR (pZ0.083). The median in-hospital stay after TEM was 4 days versus 0 days after EMR (p!0.001). The mean time of follow-up was 13 months (0-48); 56 patients (19%) did not have follow-up (yet). During the first control endoscopy, remnant adenoma tissue was found in 6/205 (2.9%) TEMand 6/38 (16%) EMR-patients (pZ0.006). After removal of remnant adenomas during the first control endoscopy once-only, late recurrence rates of TEM and EMR were 9.3% and 10.5% (pZ0.766). Conclusion: EMR appears equally effective, but associated with less morbidity than TEM for the treatment of large rectal adenomas. However, adenomas treated by EMR were slightly smaller and the retrospective nature of this study likely has introduced selection bias. A prospective randomized comparison (TREND study) seems imperative to determine which technique is more cost-effective.
T1407 Magnifying Zoom Imaging and Spectral Estimation Technology for the Endoscopic Differential Diagnosis of Subtypes of Hyperplastic Colorectal Polyps Claudio R. Teixeira, Erica Tozawa, Ronaldo J. Torresini, Mauro Maia, Eunice B. Toneloto New histopathologic evidence demonstrated distinct subtypes of hyperplastic epithelial polyps. There is the goblet cell-type hyperplastic polyp (GC), the vesicular cell-type hyperplastic polyp (VC), and the serrated adenoma (SA). While the majority of hyperplastic polyps are not related to colorectal carcinogenesis, the serrated dysplastic polyps might progress to colorectal carcinoma. With high resolution and magnifying zoom imaging along with spectral estimation technology (FICE) it is possible a detailed in vivo examination of the superficial microstructure of colorectal lesions. Aim: To evaluate differences on the superficial microstructure (pits, microvessels) among colorectal hyperplastic polyps correlating their endoscopic aspects with the histopathologic findings. Methods: A total of 54 lesions (polyps and flat lesions) were evaluated with the Fujinon 4400 processor and 590 series colonoscope that allows FICE and magnifying zoom imaging of 100. All macroscopic features were evaluated but the pit pattern (modified Kudo) and the capillary vessel patterns were the focus of the study. Mean size of the lesions was 5.4 þ/1.2mm. According to histopathologic examination there were 8 polyps GC type, 36 polyps VC type and 10 lesions SA type. All GC polyps presented enlarged square-shaped pits and hipovascularity with rare capillaries on the surface. VC type polyps presented star shaped pits and the majority (28/36) exhibited a typical capillary pattern characterized by sparse, short and straight vessels with tiny ramifications. SA lesions showed a mixed pattern composed of linear and star-shaped enlarged pits. Half of the SA lesions were hypovascular and half showed numerous spiral and tortuous capillary vessels on the surface. Conclusion: Detailed endoscopic analysis of the pit and the capillary vessel patterns of colorectal polyps by magnifying zoom imaging and FICE helps the in vivo differential diagnosis between subtypes of colorectal hyperplastic polyps and serrated adenomas.
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lesion raised histologic diagnostic yield. Thus, our study suggests colonoscopy might be more helpful than sigmoidoscopy to diagnose GVHD in patients with aHSCT. Endoscopic findings Colonoscopy Sigmoidoscopy Histologic confirmation
Normal (%)
MpD(%)
) Up (%)
4 (12.1) 10 (31.3) 1 (7)
13 (39.4) 15 (46.9) 17 (61)
16 (48.5) 7 (21.9) 20 (87)
þ Mucosal change predominant)Ulcer predominant
T1404 Double Balloon Colonoscopy: First Experience with a Dedicated Endoscope-Overtube System in Patients with Previous Difficult and Incomplete Colonoscopy Michel Delvaux, Muriel Frederic, Isaac Fassler, Gerard Gay The technique of double balloon endoscopy developed for retrograde enteroscopy has been used to perform colonoscopy in patients with difficult progression of the endoscope. A new endoscopic system, the double balloon colonoscope (DBC) has recently been developed (EC-450B15 Fujinon Optical, Saitama, Japan). The aim of this study was to evaluate the ability of DBC to achieve a complete colonoscopy in patients in whom it previously failed in order to determine indications and refine technical stipulations. Patients and Method: From January 2007 to June 2008, a DBC was proposed to all patients having undergone an incomplete colonoscopy, excluding failures due to poor bowel cleansing. After cleansing with 22L PEG, colonoscopy was performed under general anaesthesia with Propofol delivered by an anaesthesiologist, with an EC-450B15, 182 cm long, thin colonoscope (diameter 9.4 mm), an operating channel of 2.8 mm and a view angle of 140 . The overtube is 101cm long and 13.2 mm in diameter. The distal end of both the endoscope and the overtube are equipped with a latex balloon that can be inflated/deflated under control of a barostatic pump. Completeness of the colonoscopy was defined as the possibility to maintain the endoscope in a stable position in the caecum. Indication, reason for failure of previous colonoscopy, time to reach the caecum, need for fluoroscopic control of the progression and adverse events were prospectively recorded. Results: 81 patients (57 men, 24 women, mean age 56 16 years) a first colonoscopy attempt failed in our endoscopy unit (nZ44) or another one (nZ37) because of post-surgical peritoneal adhesions (n Z 4), a fixed colonic angle (nZ42), a dolichocolon (nZ30), a tight diverticulosis (nZ5). DBC was complete in 79 patients (97.5%), reaching the caecum in 49, the terminal ileum in 23 and the ileo-colonic anastomosis in 7. The DBC failed to reach the caecum and was limited to the transverse colon in 2 patients: one acromegalic female patient and one male patient with an adult Hirshprung’s disease. The mean duration of the DBC was 2418 min, similar to the mean duration of a classical colonoscopy in our unit. A relevant diagnosis was obtained in 58 patients (74.4%). All needed biopsies could be performed and a polypectomy was performed in 16 patients. No complication was observed. Conclusion: DBC enables full colonic examination in patients with previous difficult colonoscopy. The procedure is safe, can be performed by an endoscopist with the help of a trained endoscopy nurse and fluoroscopic control of the progression is necessary only in the most difficult cases.
T1405 Endoscopic Management of Massive Acute Lower Gastrointestinal Bleeding Paulo Correa, Marcelo Averbach, Jose Paccos, Giulio F. Rossini, Oswaldo W. Marques, Pedro Popoutchi Background: The management of moderate or massive acute lower intestinal bleeding (ALIB) is not well established. Although there are several strategies for the diagnosis and treatment of patients with ALIB we believe that colonoscopy within 6 hours of its presentation can be performed safely with a high rate of success in localizing and often treating the specific cause of bleeding. Aim: To assess the role of early colonoscopy as the primary method of evaluation in patients with ALIB. Methods: From January 1986 to October 2008, 29209 colonoscopies were performed in the endoscopy unit of Sı´rio Libaneˆs Hospital, Sao Paulo. Two hundred and thirty (0,79%) were urgent due to ALIB. After clinical stabilization the patients received an anterograde bowel preparation and the exams were done always under sedation. Results: Definitive diagnosis was accurate in 147 patients (64%). Diverticula (16 patients), Post-Polypectomy (16) and Angiodysplasia (14) were the predominant sources of bleeding. In 69 patients (49%) a specific therapeutic intervention was done, including fulguration (13 patients), endoscopic injection of sclerosing agents (34), APC (10), metallic endoscopic clips (10) and elastic band ligation (2). Control of active hemorrhage was achieved endoscopically in 100% of these patients. Conclusions: These data shows the importance of early colonoscopy in the management of patients with acute lower intestinal bleeding making possible its diagnosis and treatment.
AB288 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
T1406 Endoscopic Mucosal Resection Appears Equally Effective, But Is Associated with Less Morbidity Than Transanal Endoscopic Microsurgery for the Treatment of Large Rectal Adenomas Frank J. Van Den Broek, Joyce Van Schooten, Willem Bemelman, Eelco J. De Graaf, Paul Fockens, Evelien Dekker Introduction: Large rectal adenomas are currently being treated by either transanal endoscopic microsurgery (TEM) or piecemeal endoscopic mucosal resection (EMR). EMR is likely to be associated with lower morbidity, although this potential advantage may become irrelevant if these treatments are not equally effective. We conducted a retrospective study to compare the safety and effectiveness of TEM vs. EMR for the treatment of large rectal adenomas. Methods: Data were collected from patients with a preoperative diagnosis of a large rectal adenoma (O2 cm) who underwent TEM or EMR in 8 Dutch hospitals from January 2004-December 2007. Patient and procedure related characteristics, as well as complications and recurrences were registered. Since EMR may require several attempts to achieve complete removal of adenomas, two recurrence rates were defined: early and late recurrences (including and not including remnant adenomas successfully re-treated during the first control endoscopy). Results: In total, 248 patients were treated by TEM and 51 by EMR (144 male; mean 67 yrs). With respect to sex and age, there were no differences between TEM and EMR; however, adenomas treated by EMR were located higher in the rectum (mean 9.4 vs. 6.7cm ab ano) and were smaller in size (median 30 vs. 40 mm; p!0.001). Histological evaluation of the resection specimen revealed unexpected invasive cancer in 11.3% after TEM and 3.9% after EMR (pZ0.278). Intra-operative perforation occurred in 29 TEM procedures (12%) and in none of the EMR procedures (pZ0.007). Postoperative complications occurred in 69 patients (28%; major 8.5%) after TEM and in 5 patients (9.8%; major 0%) after EMR (pZ0.007). Complications needing operative intervention occurred in 16 (6.5%) patients after TEM versus no patients after EMR (pZ0.083). The median in-hospital stay after TEM was 4 days versus 0 days after EMR (p!0.001). The mean time of follow-up was 13 months (0-48); 56 patients (19%) did not have follow-up (yet). During the first control endoscopy, remnant adenoma tissue was found in 6/205 (2.9%) TEMand 6/38 (16%) EMR-patients (pZ0.006). After removal of remnant adenomas during the first control endoscopy once-only, late recurrence rates of TEM and EMR were 9.3% and 10.5% (pZ0.766). Conclusion: EMR appears equally effective, but associated with less morbidity than TEM for the treatment of large rectal adenomas. However, adenomas treated by EMR were slightly smaller and the retrospective nature of this study likely has introduced selection bias. A prospective randomized comparison (TREND study) seems imperative to determine which technique is more cost-effective.
T1407 Magnifying Zoom Imaging and Spectral Estimation Technology for the Endoscopic Differential Diagnosis of Subtypes of Hyperplastic Colorectal Polyps Claudio R. Teixeira, Erica Tozawa, Ronaldo J. Torresini, Mauro Maia, Eunice B. Toneloto New histopathologic evidence demonstrated distinct subtypes of hyperplastic epithelial polyps. There is the goblet cell-type hyperplastic polyp (GC), the vesicular cell-type hyperplastic polyp (VC), and the serrated adenoma (SA). While the majority of hyperplastic polyps are not related to colorectal carcinogenesis, the serrated dysplastic polyps might progress to colorectal carcinoma. With high resolution and magnifying zoom imaging along with spectral estimation technology (FICE) it is possible a detailed in vivo examination of the superficial microstructure of colorectal lesions. Aim: To evaluate differences on the superficial microstructure (pits, microvessels) among colorectal hyperplastic polyps correlating their endoscopic aspects with the histopathologic findings. Methods: A total of 54 lesions (polyps and flat lesions) were evaluated with the Fujinon 4400 processor and 590 series colonoscope that allows FICE and magnifying zoom imaging of 100. All macroscopic features were evaluated but the pit pattern (modified Kudo) and the capillary vessel patterns were the focus of the study. Mean size of the lesions was 5.4 þ/1.2mm. According to histopathologic examination there were 8 polyps GC type, 36 polyps VC type and 10 lesions SA type. All GC polyps presented enlarged square-shaped pits and hipovascularity with rare capillaries on the surface. VC type polyps presented star shaped pits and the majority (28/36) exhibited a typical capillary pattern characterized by sparse, short and straight vessels with tiny ramifications. SA lesions showed a mixed pattern composed of linear and star-shaped enlarged pits. Half of the SA lesions were hypovascular and half showed numerous spiral and tortuous capillary vessels on the surface. Conclusion: Detailed endoscopic analysis of the pit and the capillary vessel patterns of colorectal polyps by magnifying zoom imaging and FICE helps the in vivo differential diagnosis between subtypes of colorectal hyperplastic polyps and serrated adenomas.
www.giejournal.org