Usefulness of cap-assisted colonoscopy during colonoscopic EMR: a randomized, controlled trial

Distal Endoscopic Attachments

Endoscopy is an evolving science and the last two decades has seen it expand exponentially at a pace unapparelled in the past. With the advancement in new procedures like image-enhanced endoscopy, magnifying endoscopy, third space endoscopy, and highly advanced endoscopic ultrasound procedures, endoscopic accessories are also evolving to cater the unmet needs. Endoscopic cap or distal attachment cap is a simple but very important accessory in the endoscopists' armamentarium which has changed the path of endoscopic procedures. It has so far been used commonly mostly for variceal ligation and endoscopic mucosal resections for colorectal polyps. But the horizon of its use has expanded in the recent years for difficult clinical scenarios like providing stability to the endoscope, overcoming blind spots during screening colonoscopies, maintaining clear field of vision during endotherapy of gastrointestinal bleeding, and during magnification endoscopy for lesion characterizations and so on. These caps are of different shapes, sizes, colors, and material depending on manufacturers and their implications while performing varied endoscopies. This review summarizes the clinical utilities of the cap in diagnostic as well as therapeutic endoscopy and its expanding indications of use.

Cap-assisted EMR versus standard inject and cut EMR for treatment of large colonic laterally spreading tumors: a randomized multicenter study (with videos)

BACKGROUND AND AIMS

Piecemeal EMR of colorectal laterally spreading tumors (LSTs) >20 mm is effective. Experience is limited in the use of cap-assisted EMR (EMR-C) for resection of colonic lesions. We compared the efficacy and the safety of EMR-C for the removal of colonic LSTs ≥30 mm with "inject-and-cut" standard EMR (EMR-S).

METHODS

In this randomized trial from 4 Italian centers, 138 patients were treated with EMR-C and 102 with EMR-S. The rates of residual lesions, percentage of recurrence after 12 months, and adverse events were evaluated.

RESULTS

One hundred forty-three lesions were resected with EMR-C and 102 with EMR-S. Argon plasma coagulation (APC) was used as adjunctive treatment in 2.9% of EMR-Cs and in 22.5% of EMR-Ss (P < .001). The median time required was 20 minutes for EMR-C and 30 minutes for EMR-S (P < .001). Adverse events (AEs) occurred in 14 EMR-Cs (10.1%; 2 perforations, 11 bleeding events, and 1 stenosis) and in 22 EMR-Ss (21.6%; 1 perforation and 21 bleeding events) (P = .017). Intraprocedural AEs occurred in 3.6% of EMR-Cs and 16.7% of EMR-Ss (P = .001). Overall, residual lesions within 12 months were found to be significantly higher with EMR-S (32 patients, 31.4%) than with EMR-C (8 patients, 5.8%) (P < .001). Recurrence at follow-up colonoscopy in 12 months occurred in 7 EMR-Cs (5.1%) and 17 EMR-Ss (16.7%; P < .001).

CONCLUSIONS

The study demonstrated the feasibility and safety of EMR-C for removing large colorectal LSTs, with higher eradication rates, shorter resection time, and less use of APC when compared with EMR-S. (Clinical trial registration number: NCT03498664.).

Indications and outcomes of endoscopic resection for non-pedunculated colorectal lesions: A narrative review

In the last years, endoscopic techniques gained a crucial role in the treatment of colorectal flat lesions. At the same time, the importance of a reliable assessment of such lesions to predict the malignancy and the depth of invasion of the colonic wall emerged. The current unsolved dilemma about the endoscopic excision techniques concerns the necessity of a reliable submucosal invasive cancer assessment system that can stratify the risk of the post-procedural need for surgery. Accordingly, this narrative literature review aims to compare the available diagnostic strategies in predicting malignancy and to give a guide about the best techniques to employ. We performed a literature search using electronic databases (MEDLINE/PubMed, EMBASE, and Cochrane Library). We collected all articles about endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) registering the outcomes. Moreover, we analyzed all meta-analyses comparing EMR vs ESD outcomes for colorectal sessile or non-polypoid lesions of any size, preoperatively estimated as non-invasive. Seven meta-analysis studies, mainly Eastern, were included in the analysis comparing 124 studies and overall 22954 patients who underwent EMR and ESD procedures. Of these, eighty-two were retrospective, twenty-four perspective, nine case-control, and six cohorts, while three were randomized clinical trials. A total of 18118 EMR and 10379 ESD were completed for a whole of 28497 colorectal sessile or non-polypoid lesions > 5-10 mm in size. In conclusion, it is crucial to enhance the preoperative diagnostic workup, especially in deciding the most suitable endoscopic method for radical resection of flat colorectal lesions at risk of underlying malignancy. Additionally, the ESD necessitates further improvement because of the excessively time-consuming as well as the intraprocedural technical hindrances and related complications. We found a higher rate of en bloc resections and R0 for ESD than EMR for non-pedunculated colorectal lesions. Nevertheless, despite the lower local recurrence rates, ESD had greater perforation rates and needed lengthier procedural times. The prevailing risk for additional surgery in ESD rather than EMR for complications or oncologic reasons is still uncertain.

The Use of Attachment Devices to Aid in Adenoma Detection

PURPOSE OF REVIEW

With the intent of maximizing adenoma detection rate (ADR), different devices and colonoscopic innovations have been introduced over the past few years. There are a variety of attachment devices available for use in colonoscopy, all intended to improve ADR. In this review, we evaluate the evidence surrounding the available attachment devices and their impact on ADR.

RECENT FINDINGS

Endocuff, Endoring, Transparent cap, G-EYE balloon, and Third Eye Retroscope were all included in this review. Three of the devices, Endocuff, Endoring, and transparent hood or cap, have been shown to increase ADR without significantly altering the use of the colonoscope. Although balloon-assisted colonoscopy is not currently FDA-approved, it has the potential to increase ADR as well.

SUMMARY

Mechanical enhancement has been shown to complement the current forward-viewing colonoscope, and Endocuff appears to be the most beneficial attachment to improve ADR.

Biliary intervention using SpyGlass DS cholangioscopy through a cap-attached variable-stiffness colonoscope in a patient following Billroth II gastrectomy

The SpyGlass DS system is currently used as a direct video cholangioscope for biliary diagnostic and therapeutic procedures. In general, the SpyGlass DS cholangioscope is passed through the working channel of a duodenoscope and inserted into a bile duct via duodenal papilla. However, the procedure has been challenging in patients with altered gastrointestinal anatomy due to the retrograde route through a potentially tortuous afferent limb. A therapeutic colonoscope with variable stiffness can offer alternative guidance for SpyGlass DS cholangioscope in patients with surgically altered gastrointestinal anatomy.

Cap-assisted colonoscopy versus standard colonoscopy: is the cap beneficial? A meta-analysis of randomized controlled trials

Background:

In an effort to improve visualization during colonoscopy, a transparent plastic cap or hood may be placed on the end of the colonoscope. Cap-assisted colonoscopy (CAC) has been studied and is thought to improve polyp detection. Numerous studies have been conducted comparing pertinent clinical outcomes between CAC and standard colonoscopy (SC) with inconsistent results.

Methods:

Numerous databases were searched in November 2016. Only randomized controlled trials (RCTs) involving adult subjects that compared CAC to SC were included. Outcomes of total colonoscopy time, time to cecum, cecal intubation rate, terminal ileum intubation rate, polyp detection rate (PDR), and adenoma detection rate (ADR) were analyzed in terms of odds ratio (OR) or mean difference (MD) with fixed effect and random effects models.

Results:

Five hundred eighty-nine articles and abstracts were discovered. Of these, 23 RCTs (n=12,947) were included in the analysis. CAC showed statistically significant superiority in total colonoscopy time (MD -1.51 min; 95% confidence interval [CI] -2.67 to -0.34; P<0.01) and time to cecum (MD -0.82 min; 95%CI -1.20 to -0.44; P<0.01) compared to SC. CAC also showed better PDR (OR 1.17; 95%CI 1.06-1.29; P<0.01) but not ADR (OR 1.11; 95%CI 0.95-1.30; P=0.20). In contrast, on sensitivity analysis, ADR was better with CAC. Terminal ileum intubation and cecal intubation rates demonstrated no significant difference between the two groups (P=0.11 and P=0.73, respectively).

Conclusions:

The use of a transparent cap during colonoscopy improves PDR while reducing procedure times. ADR may improve in cap-assisted colonoscopy but further studies are required to confirm this.

The use of a transparent cap in sigmoidoscopy-A randomized controlled clinical trial on pain, time and success rate

Trials on cap-assisted colonoscopy have shown a reduction in pain, faster intubation time and a higher success rate attributed to the use of the cap. No similar studies have been published on sigmoidoscopy even though it is a common procedure associated with significant pain. Our objective was to investigate whether the use of a transparent cap for sigmoidoscopy has an impact on pain, time or success rate. To mimic the tendencies of daily clinical practice, the trainee endoscopist performed the procedures, and no analgesics or sedatives were used. We conducted a randomized, controlled clinical trial with a parallel design consisting of two groups masked for the intervention. The primary endpoint was pain, recorded on a 100-mm visual analogue scale (VAS). Our results found cap-assisted sigmoidoscopy to be significantly more painful than non-cap-assisted sigmoidoscopy (median VAS 50 vs. 38 mm; p = 0.047). We found no differences on time or success rate due to the cap. Our results suggest pain management, e.g. analgesics which is not routinely used for sigmoidoscopy, when a cap is used to gain therapeutic or diagnostic advantages. ClinicalTrials.gov Identifier: NCT02243930.

Endoscopic management of mucosal lesions in the gastrointestinal tract

With the increasing role of endoscopy in patient evaluation, more mucosal lesions, including gastric, duodenal and colonic polyps, are encountered during routine examinations. It is imperative for gastroenterologists to become familiar with the endoscopic management of these various gastrointestinal lesions. In this article, various resection techniques will be discussed, including hot/cold forceps polypectomy, hot/cold snare polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection. The article will also discuss the evidence regarding the efficacy and safety of these techniques and the future direction of endoscopic management of mucosal lesions in the gastrointestinal tract.

Improving the utility of colonoscopy: Recent advances in practice

Colonoscopy is a frequently performed diagnostic and therapeutic test and the primary screening tool in several nationalized bowel cancer screening programs. There has been a considerable focus on maximizing the utility of colonoscopy. This has occurred in four key areas: Optimizing patient selection to reduce unnecessary or low yield colonoscopy has offered cost-benefit improvements in population screening. Improving quality assurance, through the development of widely accepted quality metrics for use in individual practice and the research setting, has offered measurable improvements in colonoscopic yield. Significant improvements have been demonstrated in colonoscopic technique, from the administration of preparation to the techniques employed during withdrawal of the colonoscope. Improved techniques to avoid post-procedural complications have also been developed-further maximizing the utility of colonoscopy. The aim of this review is to summarize the recent evidence-based advances in colonoscopic practice that contribute to the optimal practice of colonoscopy.

Improved Techniques for Endoscopic Mucosal Resection (EMR) in Colorectal Adenoma

Background

Endoscopic therapy of colorectal adenomas and early cancers is a standard method. Besides oncological criteria, the method is limited by polyp location, size, and texture.

Method

Based on the current literature, technical modifications and developments in endoscopic mucosal resection are described.

Results

Numerous approaches exist to improve the conditions of resection, including optimisation of mucosal elevation and modification of techniques, tools, and devices.

Conclusion

Endoscopic therapy of sessile and flat colorectal polyps remains a challenge. Some of the presented modifications can help to address this challenge.

Tips and tricks for better endoscopic treatment of colorectal tumors: usefulness of cap and band in colorectal endoscopic mucosal resection

Endoscopic mucosal resection (EMR) is an endoscopic alternative to surgical resection of mucosal and submucosal neoplastic lesions. Prior to the development of knives, EMR could be performed with accessories to elevate the lesion. After the development of various knives, en bloc resection was possible without other accessories. So, recently, simple snaring without suction or endoscopic submucosal dissection using knife in the epithelial lesions such as adenoma or early mucosal cancer has been performed. However, for easy and complete resection of subepithelial lesions such as carcinoid tumor, a few accessories are needed. Complete resection of rectal carcinoid tumors is difficult to achieve with conventional endoscopic resection techniques because these tumors often extend into the submucosa. The rate of positive resection margin for tumor is lower in the group of EMR using a cap (EMR-C) or EMR with a ligation device (EMR-L) than conventional EMR group. EMR-C and EMR-L (or endoscopic submucosal resection with a ligation device) may be a superior method to conventional EMR for removing small rectal carcinoid tumors.

Cap-assisted colonoscopy

Cap-assisted colonoscopy is a simple, practical, and inexpensive technique that serves several useful purposes in enhancing the performance of colonoscopy. It helps improve polyp detection by its ability to visualize otherwise blind mucosal areas on the proximal aspects of folds and flexures, although its effect on adenoma detection is inconsistent. By helping navigate the colon more efficiently, it facilitates intubation of the cecum faster, with lesser patient discomfort. Cap-assisted colonoscopy can be tried as a salvage procedure in cases of failed cecal intubation with regular colonoscopy and can be of assistance during polypectomy, especially for polyps located on the proximal aspects of folds.

Colon polypectomy: a review of routine and advanced techniques

The value of performing comprehensive screening colonoscopy with complete colon polypectomy is widely accepted. Colon cancer is a significant cause of worldwide mortality and prospective studies have proven that colonoscopic polypectomy reduces both the incidence and mortality related to this disease. Over the past few decades the array of instruments and techniques have greatly expanded to assist with the safe endoscopic removal of colon polyps. This article will review the published literature regarding efficacy and safety of standard polypectomy techniques such as snare polypectomy, electrocautery, and endoscopic mucosal resection along with newer techniques such as endoscopic submucosal dissection and combined laparoscopic techniques.

Transparent cap colonoscopy versus standard colonoscopy: a systematic review and meta-analysis

Due to the increasing demand for colonoscopy, devices to advance examination techniques are highly sought after. Several studies have examined the use of a transparent cap attached to the tip of the colonoscope, but the data are inconsistent. The aim of our study was to establish whether transparent cap colonoscopy is beneficial in the improvement of caecal intubation rate, time and polyp detection. We undertook a systematic review and meta-analysis in the form of a Cochrane review to evaluate these outcomes. We included fourteen randomised controlled trials that have been published to date. Transparent cap colonoscopy demonstrates a significant reduction in caecal intubation time, by an average of 48 s, when compared to standard colonoscopy. There was no significant difference in caecal intubation rate or polyp detection between the two groups. Despite a significant difference in caecal intubation time, the clinical significance of the transparent cap remains to be seen. We believe further research is needed to investigate this adjunct.

Benefits and limitations of cap-fitted colonoscopy in screening colonoscopy

BACKGROUND

Colonoscopy is widely used to detect colorectal cancer and to remove precancerous lesions to reduce the risk of colonic cancer.

AIMS

To examine the benefits and limitations of cap-fitted colonoscopy compared to conventional colonoscopy in terms of technical performance and colorectal adenoma detection rate.

METHODS

Screening colonoscopies performed from 2009 to 2010 with or without a transparent cap were retrospectively examined to compare the rate of successful intubation, cecal intubation time, and number, size, shape, and location of adenomas detected. An inclusion criterion was visualization of >95 % of the right colon.

RESULTS

Data from 2,301 colonoscopies (1,165 with cap-fitted colonoscopy, 1,136 without the transparent cap) were retrospectively analyzed. Procedures were performed by four experienced endoscopists. The subjects' demographic characteristics and technical performances were similar between the two methods. The only significant difference in the technical performance between the two techniques was a shorter cecal intubation time with cap-fitted colonoscopy (5.3 vs. 6.6 min; p = 0.045) by one endoscopist. The total number of adenomas detected was significantly higher with cap-fitted colonoscopy than without the cap (586 vs. 484, respectively; p < 0.0001). Adenoma detection with cap-fitted endoscopy was significantly higher in the right colon than in the left colon (19 vs. 12 %, respectively; p = 0.0001).

CONCLUSION

Cap-fitted colonoscopy did not improve the technical aspects of colonoscopy but significantly increased adenoma detection, especially in the right colon. It did not increase the detection rate of flat or depressed adenomas.

Transparent cap colonoscopy versus standard colonoscopy to improve caecal intubation

BACKGROUND

Colonoscopy is considered the gold-standard investigation for screening and diagnosis of colorectal cancer. It is also becoming increasingly desirable for assessment, management, diagnosis and follow-up of other colorectal diseases, such as inflammatory bowel diseases and acute diverticulitis. Hence, due to the increasing demand for colonoscopy, devices to advance examination techniques are highly sought-after and the colonoscope with the transparent cap could be one of these.

OBJECTIVES

To identify and review all relevant data in order to determine whether colonoscopy with a transparent cap is a more effective diagnostic tool than colonoscopy.

SEARCH METHODS

We searched the MEDLINE, EMBASE and CINAHL databases, and the Cochrane Central Register of Controlled Trials for all randomised controlled trials (RCTs) comparing the use of colonoscopy with a transparent cap with standard colonoscopy.

SELECTION CRITERIA

Studies were included if they were randomised controlled trials which compared the use of colonoscopy with a transparent cap with standard colonoscopy.

DATA COLLECTION AND ANALYSIS

Data on study methods, participants, interventions used and outcomes measured was extracted from each study. Data was entered into the Cochrane Review Manager software (RevMan 5.0, 2008) and analysed using Cochrane MetaView.

MAIN RESULTS

In the present meta-analysis, we considered 14 randomised controlled trials so far published. The findings of our work indicate that colonoscopy with transparent cap has a faster caecal intubation time when compared with standard colonoscopy. Reviewing studies individually would also seem to favour colonoscopy with transparent cap for polyp detection rate and pain during procedure but due to lack of comparable data meta-analysis was not feasible.

AUTHORS' CONCLUSIONS

This review suggests that a transparent cap on the end of the colonoscope may give a marginally faster caecal intubation time compared with standard colonoscopy. It also suggests that there is a better polyp detection rate and less pain with the cap. However, the authors feel that further randomised controlled trials in this area would provide more clinically significant information on this adjunct to colonoscopy.

A new accessory, endoscopic cuff, improves colonoscopic access for complex polyp resection and scar assessment in the sigmoid colon (with video)

BACKGROUND

Difficult and unstable endoscopic access to large sessile/flat colon polyps in the sigmoid colon may prevent successful and complete EMR.

OBJECTIVE

We report our experience with the use of an endoscopic cuff, a new endoscopic accessory, to improve endoscopic access during endoscopic therapy and scar assessment.

DESIGN

Single-center, retrospective, feasibility case series.

SETTING

Tertiary referral academic endoscopy unit.

PATIENTS

Nonconsecutive patients referred for endoscopic resection of large flat/sessile sigmoid colon polyps or surveillance of postpolypectomy scars in the sigmoid colon.

INTERVENTIONS

When conventional methods to achieve stable access and visualization were unsuccessful, the endoscopic cuff was used to retract sigmoid colon folds.

MAIN OUTCOME MEASUREMENTS

Safety, procedural success, and complications.

RESULTS

Five patients (mean age 62 years, 3 male/2 female) underwent endoscopic cuff-assisted EMR polypectomy, and 7 patients (mean age 62 years, 2 male/5 female) underwent post-EMR scar surveillance with an endoscopic cuff-assisted flexible sigmoidoscopy. All sessile/flat polyps (mean size 29 mm) or post-EMR scar sites (mean size 15 mm) were located at acute bends in the sigmoid colon. With the endoscopic cuff placed around the tip of the colonoscope, endoscopic access improved significantly by flattening/depressing colon folds close to the lesion/scar. The entire polyp/scar surface was revealed, facilitating a complete polyp excision and a meticulous scar assessment. No immediate or delayed adverse events were seen.

LIMITATIONS

Single-center, nonrandomized case series.

CONCLUSIONS

An endoscopic cuff appears to be a safe and easily used accessory to facilitate colonoscopic access for complex polypectomy and scar assessment in the sigmoid colon.

Hood colonoscopy in trainees: a useful adjunct to improve the performance

BACKGROUND

The use of a transparent hood to improve colonoscopic performance has recently been proposed.

AIMS

The purpose of this study was to evaluate whether using the hood might improve the cecal intubation rate, cecal intubation time, number of attempts needed to intubate the ileo-cecal valve, and polyp detection rate in trainees.

METHODS

Patients undergoing colonoscopy (n = 378) were randomized in two groups, one studied with hood colonoscopy (n = 179) and the other (n = 199) with standard examination.

RESULTS

No differences were found between hood and standard colonoscopy with respect to cecal intubation rate (95 vs 92 %), whereas hood colonoscopy significantly shortened the cecal intubation time, the number of attempts needed to intubate the ileo-cecal valve, and the overall polyp detection rate (p < 0.01 for all these variables).

CONCLUSIONS

Hood colonoscopy might represent a useful adjunct to standard colonoscopy, especially improving the performance of endoscopic trainees.

A new method for screening and surveillance colonoscopy: Combined water-exchange and cap-assisted colonoscopy

BACKGROUND & AIMS

Colonoscopy plays an important and central role in current colorectal cancer screening and prevention programs, but it is an imperfect tool. Adjunct techniques may help improve the performance of colonoscopy to increase the detection of polyps with neoplastic potential. This study investigates the novel approach of combined water-exchange and cap-assisted colonoscopy (WCC) and its impact on adenoma detection.

METHODS

A single-center single-colonoscopist consecutive group observational study to compare WCC with conventional air insufflation colonoscopy was performed. Data were collected from 50 consecutive patients undergoing outpatient colorectal cancer screening or polyp surveillance with WCC. Adenoma detection rates (ADR) and adenomas detected per colonoscopy (APC) were compared to a control group of 101 consecutive patients examined with conventional air colonoscopy during the immediate prior period.

RESULTS

Cecal intubation was achieved in all patients. As an emerging and alternative quality metric for colonoscopy, APC was significantly higher in the WCC group (3.08 vs. 1.50, p=0.0021). The conventional quality metric, overall ADR, was higher in the WCC group compared to the air colonoscopy group (70.0% vs. 59.4%, p=0.22). This difference was not statistically significant, likely due to a type II error.

CONCLUSION

The observational data suggest APC is a more sensitive indicator of quality colonoscopy than ADR. WCC shows promise as a novel technique that merges two simple adjunct methods to help improve the performance of colonoscopy. The data suggest larger, prospective studies are necessary to determine the true impact of water-exchange combined with cap-assisted maneuvers.

Diagnostic accuracy of probe-based confocal laser endomicroscopy and narrow band imaging in detection of dysplasia in duodenal polyps

GOALS

To estimate the accuracy of probe-based confocal laser endomicroscopy (pCLE) and narrow band imaging (NBI), individually and in combination, for classification of duodenal polyps.

BACKGROUND

Ex vivo pathologic diagnosis of duodenal polyps causes time delay, requiring separate procedures for diagnosis and therapy. It also involves small risk of pancreatitis in ampullary adenomas and can make subsequent endoscopic mucosal resection more difficult by "tacking down" mucosa. In vivo diagnosis with pCLE and NBI may avoid these complications and may guide immediate therapy.

STUDY

During high-definition white light endoscopy, 1 endoscopist (M.B.W.) performed NBI and then, pCLE of duodenal sites. Matched tissue sampling or endoscopic mucosal resection was performed. Confocal videos were recorded, de-identified, and reviewed by same endoscopist, blinded to histopathology, 1 month later. Confocal features of dysplasia in Barrett esophagus were applied for detection of duodenal dysplasia.

RESULTS

Of 65 sites from 36 participants, 24 lesions showed dysplasia, whereas 41 polyps and control sites were nondysplastic on histopathology, used as standard reference. The accuracy, sensitivity, and specificity of pCLE were 83%, 92%, and 78%, whereas that of NBI were 80%, 83%, and 78%, respectively. In subset of 49 lesions with similar pCLE and NBI diagnosis, the accuracy, sensitivity, and specificity, improved significantly and was found to be 92%, 95%, and 90%, respectively.

CONCLUSIONS

Our study suggests that pCLE has superior sensitivity as compared with NBI for detection of dysplasia in duodenal polyps. Combined accuracy of pCLE and NBI approaches that of ex vivo pathology, which may help in avoiding biopsy sampling.