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Efficacy of Small Bowel (SB) Preparation to Improve Capsule Enteroscopy Outcomes: A Systematic Review
Abstracts
advantageous for patients at high risk for pharyngeal cancer, we performed endoscopic examination of the pharyngeal area by NBI combined with conventional upper gastrointestinal endoscopy in high-risk patient groups. Objectives: To investigate the detection rate of pharyngeal cancer by endoscopic examination with NBI in high-risk groups. Subjects and Method: A total of 103 highrisk patients underwent oropharyngeal and hypopharyngeal endoscopic examination by NBI combined with conventional upper gastrointestinal endoscopy from February to October 2008. A high-risk group of pharyngeal cancer was defined as males over 50 years old who had a history of heavy drinking and smoking. We investigated the detection rate of pharyngeal cancer in that group. Result: Among all subjects, 97 (94.2%) patients experienced successful examination without severe pharyngeal reflex. The median age was 66 (range, 50 - 87 years), the necessary time for pharyngeal observation was 1 minute, 42 seconds (median, range 1.0 - 9.5 minutes), and the total examination time was 9 minutes, 40 seconds (median, range 4.5 - 13.0 minutes). There were 4 (3.9%) patients who were diagnosed with pharyngeal cancer. Two of those 4 patients ware carcinoma in situ (stage 0, AJCC 6th), and the remaining 2 were at stage I (AJCC 6th). Two had underlying advanced esophageal cancer, and one had undergone radical surgery for esophageal cancer in the past. Two patients without underlying advanced esophageal cancer underwent radical therapy for early pharyngeal cancer, and are progressing well at this time. Conclusions: The detection rate of pharyngeal cancer in the high-risk groups was 3.9% in our institution. The successful rate of the pharyngeal examination was high, and the procedure requires a short time. Therefore, we conclude that pharyngeal examination by NBI should be performed along with conventional upper gastrointestinal endoscopy in patients at high-risk for pharyngeal cancer.
M1310 Early Pharyngeal Cancers Are Good Candidates for Endoscopic Treatment Akiyoshi Ishiyama, Tomohiro Tsuchida, Etsuo Hoshino, Masahiro Igarashi, Kazuyoshi Kawabata, Noriko Yamamoto, Naoyuki Uragami, Junko Fujisaki Aim: Early pharyngeal cancers have been treated by irradiation and/or surgery. However, they often lead to the bothersome complications such as dry mouth, dysphonia and dysphagia. Thanks to the advanced endoscopic technology, narrowband imaging (NBI), many lower/middle pharyngeal cancers have been detected at their early stages. Therefore, we tried to apply the endoscopic treatment techniques, endoscopic mucosal resection (EMR) or submucosal dissection (ESD), for the treatment of early pharyngeal cancers. An aim of the present study is to elucidate the efficacy and risk of endoscopic treatment of early pharyngeal cancers. PATIENTS: Enrolled in this study were 18 male patients diagnosed between June 2006 and March 2008 to have early pharyngeal cancer by endoscopy (assisted by NBI and/or iodine stain) and computed tomography. The endoscopic examination was made under conscious sedation by midazolam. Average age of the patients was 63 years (range: 42-80). Only 2 patients complained of symptoms caused by cancer. While in other 16 patients, cancers were detected at the scheduled follow-up endoscopic examination for the previous cancer. Most of the patients had the history of head & neck (15) and/or esophageal (10) cancers. Localization of the cancer was middle (2) and lower (16) pharynx. Size of the lesion was less than 20 mm (14) and more than 20 mm (4). Methods: Treatment was performed in the operation room with the patient under general anesthesia. GI endoscopists resected the cancer with the assistance of Head/Neck surgeons to prepare the better visualization. EMR was applied for 17 patients and ESD for 1 patient. The removed specimens were histologically analysed by the pathologists. Results: All cancers were squamous cell carcinoma. Subepithelial invasion was detected in 16 specimens, but vertical cut-end was positive for cancer cells in only 1 specimen. Lymphatic or venous infiltration was detected in 3 specimens. The outcome of patients was favorable and by now the local recurrence of cancer was detected in 2 patients and cervical lymphnode metastasis was found in 1 patient. Conclusion: In the near future, endoscopic treatment will be the first step for the treatment of the early pharyngeal cancers. Histological analysis of the removed specimens by the pathologists will determine the next step treatment modalities.
M1311 Comparison of Standard Versus High Definition Colonoscopy for Polyp Detection: A Randomized Controlled Trial Georgios Tribonias, Konstantinos Konstantinidis, Emmanouil Vardas, Angeliki Theodoropoulou, Emmanouil Zois, Konstantinos Karmiris, Gregorios Chlouverakis, Gregorios A. Paspatis Background and Aims: Colonoscopy is the most commonly performed gastrointestinal procedure due to its utility in colorectal cancer screening. Detection of polyps is an important goal of colonoscopy; therefore it’s of great interest to find out endoscopic techniques associated with the highest polyps’ detection rate. In the present study, we sought to compare the performance of colonoscopy using a high definition, wide-angle colonoscope versus a standard colonoscope for the detection of polyps. The literature data regarding this issue is limited. Patients and Methods: A total of 390 patients, aged 50 years or older with
AB210 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
intact colons, submitted to routine colonoscopy, were prospectively randomized between high definition colonoscopy (HD group, n Z 193) and standard colonoscopy (SC group, n Z 197). Times required to reach and withdraw from the cecum were measured. All the examinations were performed by a single experienced endoscopist with a known high polyps’ detection rate. Sample size calculation showed that at least 182 patients on each group were needed in order to achieve a statistical power of 80% to detect a 15% increase in the number of detected polyps between the two groups at the 5% level of significance. Results: The per-patient basis analyses demonstrated that there were no significant differences between the 2 groups, as far as the overall detection rate of polyps (SC, 1.31 1.90; HD, 1.68 2.31; PZ0.085), of large polyps (sizeR10 mm; SC, 0.39 0.89; HD, 0.48 0.80; PZ0.29) and of medium polyps (10mmOsizeR5 mm; SC, 0.60 1.46; HD, 0.58 1.25; PZ0.83). In contrast, a significant difference was observed in the detection rates of small polyps (size!5mm; SC, 0.32 0.86; HD, 0.71 1.65; PZ0.004). Moreover, no significant differences between the 2 groups were observed, in the overall detection rates of adenomas, large adenomas, medium adenomas, large hyperplastic polyps and medium hyperplastic polyps. On the other hand, the detection rates of small hyperplastic polyps (SC, 0.11 0.38; HD, 0.27 0.63; PZ0.003) and small adenomas (SC, 0.21 0.63; HD, 0.44 1.17; PZ0.018), as well as the overall detection rate of hyperplastic polyps (SC, 0.20 0.48; HD, 0.35 0.69; PZ0.011) were significantly increased with high definition colonoscopes. Conclusion: High definition colonoscopy led to a significant increase in the detection of small polyps including adenomas and hyperplastic polyps.
M1312 Efficacy of Small Bowel (SB) Preparation to Improve Capsule Enteroscopy Outcomes: A Systematic Review Riccardo Marmo, Cristiano Spada, Gianluca Rotondano, Maria Elena Riccioni, Guido Costamagna Introduction: SB exploration is significantly limited in some cases by the presence of debris, bile, bubbles and blood that may hide findings or because of incomplete SB transit of capsule endoscopy (CE). Studies on the effect of bowel preparation (prep) on SB visualization using different agents yielded contradictory results and a standardized protocol has not been established. Aims and Methods: Primary aim was to evaluate if bowel prep may affect the quality of SB visualization; secondary aims were to evaluate if prep may increase the diagnostic yield (DY) of CE and affect the rate of complete exploration. We conducted a quantitative systematic review searching the PubMed, Embase, and Cochrane Library databases up to October 31, 2008 using the terms: ‘‘capsule endoscopy or enteroscopy’’, ‘‘preparation’’ and ‘‘cleaning or cleansing’’. All papers identified were examined. Additional references were identified from the reference lists. Two reviewers independently checked each trial for fulfilment of predefined inclusion criteria. Both the reviewers were expert in content matter. Results: 59 studies were initially identified. 44 were excluded after review, leaving 17 papers appropriate for meta-analysis. There was complete agreement among reviewers regarding decisions on trial inclusion in the analysis. In the proximal segment, purge prep significantly improves the quality of capsule images by almost 30% (M-H pooled RR 1.29 [95% CI 1.06-1.56] p!0.01) with no heterogeneity among results (pZ0.18). Addition of a prokinetic agent increases the degree of cleansing three-fold (RR 3.04 [95% CI 1.13-8.11]), whereas the adjunct of simeticone provides a two-fold improvement (RR 2.02 [95% CI 1.11-3.65]). In the distal segment, prep provides an even more relevant improvement in the degree of cleansing, of about 50% (RR 1.54 [95% CI 1.21-1.97] p!0.001), but there is significant heterogeneity (chi-squaredZ12.22, pZ0.094). The use of PEG prokinetic agents significantly improves quality of prep (RR 1.53 [95% CI 1.06-2.20] p!0.02), whereas Phospho-Soda yields results similar to no prep (RR 1.19 [95% CI 0.75-1.67] pZ0.59). Pooled data homogeneously show that SB prep does not increase the number of positive findings (RR 1.04 [95% CI 0.88-1.22] pZ 0.65), nor the rate of cecum visualization (RR 1.024 [95% CI 0.93-1.12] pZ0.61). Conclusion: prep significantly improves the quality of CE images both in the proximal and, to an even greater extent, in the distal segment of SB. The use of PEG and simeticone or prokinetics is currently the combination offering the highest level of image quality. Bowel prep has no impact on DY, and does not increase cecum visualization.
M1313 Lower Body Weight Is Associated with Increased Electrolyte Disturbances After Fleet’s Phospho-Soda: A Clinical Pharmacokinetic Study Eli D. Ehrenpreis Introduction: Fleet’s Phospho-Soda is a common colonoscopy preparation requiring the ingestion of 39.6 grams of sodium phosphate. Multiple electrolyte disturbances have been reported after Fleet’s Phospho-Soda. Body weight has not been examined as a risk factor for these abnormalities. Methods: This is the initial report of an ongoing clinical trial. After an overnight fast, six normal subjects, aged 23-58, consumed 45 mL Fleet’s Phospho-soda with 1250 mL clear liquids. Three females, (group I) weighed less than 65 kg, one female and two males (group II), weighed more than 100 kg. Average weight and lean body mass (LBM) in group I were 60 and 39.5 kg and was 118 and 76 kg in group II. Baseline serum calcium
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advantageous for patients at high risk for pharyngeal cancer, we performed endoscopic examination of the pharyngeal area by NBI combined with conventional upper gastrointestinal endoscopy in high-risk patient groups. Objectives: To investigate the detection rate of pharyngeal cancer by endoscopic examination with NBI in high-risk groups. Subjects and Method: A total of 103 highrisk patients underwent oropharyngeal and hypopharyngeal endoscopic examination by NBI combined with conventional upper gastrointestinal endoscopy from February to October 2008. A high-risk group of pharyngeal cancer was defined as males over 50 years old who had a history of heavy drinking and smoking. We investigated the detection rate of pharyngeal cancer in that group. Result: Among all subjects, 97 (94.2%) patients experienced successful examination without severe pharyngeal reflex. The median age was 66 (range, 50 - 87 years), the necessary time for pharyngeal observation was 1 minute, 42 seconds (median, range 1.0 - 9.5 minutes), and the total examination time was 9 minutes, 40 seconds (median, range 4.5 - 13.0 minutes). There were 4 (3.9%) patients who were diagnosed with pharyngeal cancer. Two of those 4 patients ware carcinoma in situ (stage 0, AJCC 6th), and the remaining 2 were at stage I (AJCC 6th). Two had underlying advanced esophageal cancer, and one had undergone radical surgery for esophageal cancer in the past. Two patients without underlying advanced esophageal cancer underwent radical therapy for early pharyngeal cancer, and are progressing well at this time. Conclusions: The detection rate of pharyngeal cancer in the high-risk groups was 3.9% in our institution. The successful rate of the pharyngeal examination was high, and the procedure requires a short time. Therefore, we conclude that pharyngeal examination by NBI should be performed along with conventional upper gastrointestinal endoscopy in patients at high-risk for pharyngeal cancer.
M1310 Early Pharyngeal Cancers Are Good Candidates for Endoscopic Treatment Akiyoshi Ishiyama, Tomohiro Tsuchida, Etsuo Hoshino, Masahiro Igarashi, Kazuyoshi Kawabata, Noriko Yamamoto, Naoyuki Uragami, Junko Fujisaki Aim: Early pharyngeal cancers have been treated by irradiation and/or surgery. However, they often lead to the bothersome complications such as dry mouth, dysphonia and dysphagia. Thanks to the advanced endoscopic technology, narrowband imaging (NBI), many lower/middle pharyngeal cancers have been detected at their early stages. Therefore, we tried to apply the endoscopic treatment techniques, endoscopic mucosal resection (EMR) or submucosal dissection (ESD), for the treatment of early pharyngeal cancers. An aim of the present study is to elucidate the efficacy and risk of endoscopic treatment of early pharyngeal cancers. PATIENTS: Enrolled in this study were 18 male patients diagnosed between June 2006 and March 2008 to have early pharyngeal cancer by endoscopy (assisted by NBI and/or iodine stain) and computed tomography. The endoscopic examination was made under conscious sedation by midazolam. Average age of the patients was 63 years (range: 42-80). Only 2 patients complained of symptoms caused by cancer. While in other 16 patients, cancers were detected at the scheduled follow-up endoscopic examination for the previous cancer. Most of the patients had the history of head & neck (15) and/or esophageal (10) cancers. Localization of the cancer was middle (2) and lower (16) pharynx. Size of the lesion was less than 20 mm (14) and more than 20 mm (4). Methods: Treatment was performed in the operation room with the patient under general anesthesia. GI endoscopists resected the cancer with the assistance of Head/Neck surgeons to prepare the better visualization. EMR was applied for 17 patients and ESD for 1 patient. The removed specimens were histologically analysed by the pathologists. Results: All cancers were squamous cell carcinoma. Subepithelial invasion was detected in 16 specimens, but vertical cut-end was positive for cancer cells in only 1 specimen. Lymphatic or venous infiltration was detected in 3 specimens. The outcome of patients was favorable and by now the local recurrence of cancer was detected in 2 patients and cervical lymphnode metastasis was found in 1 patient. Conclusion: In the near future, endoscopic treatment will be the first step for the treatment of the early pharyngeal cancers. Histological analysis of the removed specimens by the pathologists will determine the next step treatment modalities.
M1311 Comparison of Standard Versus High Definition Colonoscopy for Polyp Detection: A Randomized Controlled Trial Georgios Tribonias, Konstantinos Konstantinidis, Emmanouil Vardas, Angeliki Theodoropoulou, Emmanouil Zois, Konstantinos Karmiris, Gregorios Chlouverakis, Gregorios A. Paspatis Background and Aims: Colonoscopy is the most commonly performed gastrointestinal procedure due to its utility in colorectal cancer screening. Detection of polyps is an important goal of colonoscopy; therefore it’s of great interest to find out endoscopic techniques associated with the highest polyps’ detection rate. In the present study, we sought to compare the performance of colonoscopy using a high definition, wide-angle colonoscope versus a standard colonoscope for the detection of polyps. The literature data regarding this issue is limited. Patients and Methods: A total of 390 patients, aged 50 years or older with
AB210 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
intact colons, submitted to routine colonoscopy, were prospectively randomized between high definition colonoscopy (HD group, n Z 193) and standard colonoscopy (SC group, n Z 197). Times required to reach and withdraw from the cecum were measured. All the examinations were performed by a single experienced endoscopist with a known high polyps’ detection rate. Sample size calculation showed that at least 182 patients on each group were needed in order to achieve a statistical power of 80% to detect a 15% increase in the number of detected polyps between the two groups at the 5% level of significance. Results: The per-patient basis analyses demonstrated that there were no significant differences between the 2 groups, as far as the overall detection rate of polyps (SC, 1.31 1.90; HD, 1.68 2.31; PZ0.085), of large polyps (sizeR10 mm; SC, 0.39 0.89; HD, 0.48 0.80; PZ0.29) and of medium polyps (10mmOsizeR5 mm; SC, 0.60 1.46; HD, 0.58 1.25; PZ0.83). In contrast, a significant difference was observed in the detection rates of small polyps (size!5mm; SC, 0.32 0.86; HD, 0.71 1.65; PZ0.004). Moreover, no significant differences between the 2 groups were observed, in the overall detection rates of adenomas, large adenomas, medium adenomas, large hyperplastic polyps and medium hyperplastic polyps. On the other hand, the detection rates of small hyperplastic polyps (SC, 0.11 0.38; HD, 0.27 0.63; PZ0.003) and small adenomas (SC, 0.21 0.63; HD, 0.44 1.17; PZ0.018), as well as the overall detection rate of hyperplastic polyps (SC, 0.20 0.48; HD, 0.35 0.69; PZ0.011) were significantly increased with high definition colonoscopes. Conclusion: High definition colonoscopy led to a significant increase in the detection of small polyps including adenomas and hyperplastic polyps.
M1312 Efficacy of Small Bowel (SB) Preparation to Improve Capsule Enteroscopy Outcomes: A Systematic Review Riccardo Marmo, Cristiano Spada, Gianluca Rotondano, Maria Elena Riccioni, Guido Costamagna Introduction: SB exploration is significantly limited in some cases by the presence of debris, bile, bubbles and blood that may hide findings or because of incomplete SB transit of capsule endoscopy (CE). Studies on the effect of bowel preparation (prep) on SB visualization using different agents yielded contradictory results and a standardized protocol has not been established. Aims and Methods: Primary aim was to evaluate if bowel prep may affect the quality of SB visualization; secondary aims were to evaluate if prep may increase the diagnostic yield (DY) of CE and affect the rate of complete exploration. We conducted a quantitative systematic review searching the PubMed, Embase, and Cochrane Library databases up to October 31, 2008 using the terms: ‘‘capsule endoscopy or enteroscopy’’, ‘‘preparation’’ and ‘‘cleaning or cleansing’’. All papers identified were examined. Additional references were identified from the reference lists. Two reviewers independently checked each trial for fulfilment of predefined inclusion criteria. Both the reviewers were expert in content matter. Results: 59 studies were initially identified. 44 were excluded after review, leaving 17 papers appropriate for meta-analysis. There was complete agreement among reviewers regarding decisions on trial inclusion in the analysis. In the proximal segment, purge prep significantly improves the quality of capsule images by almost 30% (M-H pooled RR 1.29 [95% CI 1.06-1.56] p!0.01) with no heterogeneity among results (pZ0.18). Addition of a prokinetic agent increases the degree of cleansing three-fold (RR 3.04 [95% CI 1.13-8.11]), whereas the adjunct of simeticone provides a two-fold improvement (RR 2.02 [95% CI 1.11-3.65]). In the distal segment, prep provides an even more relevant improvement in the degree of cleansing, of about 50% (RR 1.54 [95% CI 1.21-1.97] p!0.001), but there is significant heterogeneity (chi-squaredZ12.22, pZ0.094). The use of PEG prokinetic agents significantly improves quality of prep (RR 1.53 [95% CI 1.06-2.20] p!0.02), whereas Phospho-Soda yields results similar to no prep (RR 1.19 [95% CI 0.75-1.67] pZ0.59). Pooled data homogeneously show that SB prep does not increase the number of positive findings (RR 1.04 [95% CI 0.88-1.22] pZ 0.65), nor the rate of cecum visualization (RR 1.024 [95% CI 0.93-1.12] pZ0.61). Conclusion: prep significantly improves the quality of CE images both in the proximal and, to an even greater extent, in the distal segment of SB. The use of PEG and simeticone or prokinetics is currently the combination offering the highest level of image quality. Bowel prep has no impact on DY, and does not increase cecum visualization.
M1313 Lower Body Weight Is Associated with Increased Electrolyte Disturbances After Fleet’s Phospho-Soda: A Clinical Pharmacokinetic Study Eli D. Ehrenpreis Introduction: Fleet’s Phospho-Soda is a common colonoscopy preparation requiring the ingestion of 39.6 grams of sodium phosphate. Multiple electrolyte disturbances have been reported after Fleet’s Phospho-Soda. Body weight has not been examined as a risk factor for these abnormalities. Methods: This is the initial report of an ongoing clinical trial. After an overnight fast, six normal subjects, aged 23-58, consumed 45 mL Fleet’s Phospho-soda with 1250 mL clear liquids. Three females, (group I) weighed less than 65 kg, one female and two males (group II), weighed more than 100 kg. Average weight and lean body mass (LBM) in group I were 60 and 39.5 kg and was 118 and 76 kg in group II. Baseline serum calcium
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