Patient-posture and Ileal-intubation during colonoscopy (PIC): a randomized controlled open-label trial

Assessment of Anatomical Morphology of the Ileocecal Junction and Ileocecal Valve by Dissection and Endoscopy

INTRODUCTION

The ileocecal valve (ICV) guards the opening of the ileocecal junction (ICJ) and acts as a mechanical barrier to prevent the reflux of material from the colon into the ileum. The morphology of the ICV noted in living is different from that of cadavers. The ICV is better studied in the living by endoscopy. A study of variation in the gross anatomy of the ICV can help determine the factors responsible for its competency.

MATERIALS AND METHODS

A descriptive study was conducted on a total of 85 (N) patients each in two groups over a period of two years. Group I: 85 specimens of the ileocecal region obtained during dissection; Group 2: 85 patients undergoing colonoscopic study undertaken in the Department of Medical Gastroenterology. In the dissection method, the apparently normal ICJ was inspected, photographed, and measured using Vernier calipers. In the colonoscopy method, the procedure was observed and while observing ICV, photos were taken. These photographs were later compared with other photographs in the literature to identify the morphology of ICV. The age, gender, location, and morphology of ICV were represented in percentile, and qualitative variables were analyzed by Pearson correlation coefficient.

RESULTS

Out of 85 participants in Group A, 80% (68) were males and 20% (17) were females; in Group B, 58% (49) were males, and the remaining 42% (36) were females. In the dissection method out of 85 (N) patients, 98% had reverse S type terminal ileum, correlation of diameter of ICV with age p=0.003 and correlation of morphology of ICV with age p=0.006, and was statistically significant. In the colonoscopy method, 58% were males and 22% of them were 31-40 years. In 49% of patients, ICV was viewed from the left lateral position. The correlation of success of ileoscopy with age (p=0.608), gender (p=0.896), the position of the patient (p=0.236), and morphology of ICV (p=0.631) was not statistically significant.

CONCLUSION

There were no age-related changes observed regarding the morphology of the ICJ. It was found that as age increases diameter of ICV increases. The success of ileoscopy was highest in 31-40 years of age.

Different position from traditional left lateral for colonoscopy? A meta-analysis and systematic review of randomized control trials

BACKGROUND

Colonoscopy requires the intubation of the cecum for screening of colorectal diseases. The conventional position used for colonoscopy is the left lateral position (LLP). However, alternative positions have also been utilized to enhance the success of intubation. Thus, the aim of this study was to perform a meta-analysis of the different positions to determine the effectiveness of the individual positions for successful colonoscopy.

METHODS

Medline, Embase and Cochrane trials electronic databases were searched for studies on colonoscopy positions. The primary outcome was defined as the cecal intubation rate. Pooled risk ratios (RR) and 95% confidence intervals (CI) for the rates of cecal intubation were estimated. Secondary outcomes such as the cecal intubation time and adenoma detection rate were further analyzed qualitatively.

RESULTS

After reviewing 644 identified records, 7 randomized control trials (RCT) studies were included. No significant difference was observed in either comparisons, between the LLP vs. supine position (SP) (RR = 1.01, 95% CI, 0.98 to 1.04, P = 0.55) or the LLP vs. prone position (PP) (RR = 1.02, 95% CI, 0.98 to 1.06, P = 0.27).

CONCLUSIONS

Amidst available literature, the use of other positions can be considered when performing colonoscopy. These further highlights that the existential practice is based predominantly on familiarity instead of evidence-based-research.

Terminal ileum intubation is not associated with colonoscopy quality measures

BACKGROUND AND AIM

Intubation of the terminal ileum (TI) demonstrates a complete colonoscopy, but its clinical value during screening exams is unknown. We aimed to determine whether TI intubation during screening colonoscopy is associated with colonoscopy quality measures or identifies subclinical pathology.

METHODS

We performed a retrospective cohort study examining average-risk screening colonoscopies performed at an academic health system between July 2016 and October 2017. Data were extracted from an internal colonoscopy quality registry and the electronic health record. Appropriate statistical tests were used for group comparisons, to correlate TI intubation rate (TIIR) with measures of colonoscopy quality and to examine factors associated with the likelihood of TI intubation.

RESULTS

There were 7799 colonoscopies performed with adequate prep quality by 28 gastroenterologists. Most patients were female (56.4%) with a median age of 58. The median TIIR was 37.0%, with significant variability among physicians (2-93%). The detection rates for all polyps, adenomas, and sessile serrated polyps were 62.1%, 45.5%, and 7.2%, respectively, and none correlated with TIIR. Intubation of the TI was associated with significantly longer withdrawal times. In a random 10% sample of cases with TI intubation, no clinically significant pathology was found.

CONCLUSIONS

There is wide variability in TIIR among endoscopists. Except to provide photodocumentation of exam extent when other images may be difficult to obtain, the lack of correlation between TI intubation and meaningful clinical outcomes together with the associated time costs suggest routine TI intubation during screening colonoscopy may not be warranted.

Radiological Response Is Associated with Better Outcomes and Should Be Considered a Therapeutic Target in Crohn's Disease

BACKGROUND

The aim of the study was to identify factors associated with a radiological response and to assess the impact of radiological improvement in long-term outcomes in small bowel (SB) Crohn's disease (CD) patients.

METHODS

We performed a retrospective study from June 2011 to June 2017 in the tertiary center, Claude Huriez Hospital in Lille, France. All SB CD patients, who underwent two magnetic resonance enterographies (MRE) 3-12 months apart, with at least 1-year follow-up after the second MRE, were included. Signs of radiological inflammation were identified by two expert radiologists in CD. Patients were classified as radiological responders (RR) and non-responders (NR). Hospitalization rates, adjustment of treatment, and surgical or endoscopic interventions were assessed and compared between RR and NR. Factors associated with a radiological response were also studied using the Cox model.

RESULTS

One hundred and fifteen SB CD patients were included with a median follow-up of 17 months (IQR 11.6-28.3). There were 54 (47%) RR and 61 (53%) NR. The risk of surgical or endoscopic intervention was higher in NR than RR (p = 0.04), and the median delay until a surgical or endoscopic intervention was shorter in NR (p = 0.04). Multifocal disease, a hypersignal on diffusion-weighted or dynamic contrast-enhanced imaging, a stricture, or a fistula was significantly associated with a decreased probability of a radiological response (p < 0.05).

CONCLUSION

This study shows that a radiological response is associated with a decreased risk of surgical or endoscopic intervention and should be considered as a therapeutic target in CD patients.