Role of Full-spectrum Endoscopy in Colorectal Cancer Screening: Randomized Trial

GOALS

The aim of this study was to compare a new, full-spectrum endoscope (Fuse; EndoChoice, Alpharetta, GA) to standard forward-viewing colonoscopy in the detection of colorectal neoplasms.

BACKGROUND

Colonoscopy, the gold standard for the detection of colorectal cancer, fails to detect 22% to 28% of polyps, increasing the risk of interval cancer. Endoscopic improvement of the adenoma detection rate decrease interval carcinomas. Full-spectrum endoscopy (FUSE) (330-degree field of view), in a tandem study, has been shown to reduce the adenoma miss rate.

STUDY

Prospective, randomized study of 249 patients in patients referred from the colorectal screening program with a positive fecal occult blood test (FOBT). Patients were randomized to standard forward-viewing colonoscopy (170 degrees) or to full-spectrum colonoscopy with the Fuse system (330 degrees). Study variables were the adenoma detection rate, the polyp detection rate, the mean number of adenomas per procedure, the lesions detected according to the location, morphology and size, cecal intubation rate, total procedure time, insertion time to the cecum, therapeutic success, and adverse events.

RESULTS

The Fuse system did not produce a significantly higher adenoma detection rate than standard forward-viewing colonoscopy (FUSE 73.1% vs. standard colonoscopy 68.1%; P=0.47) but did have a significantly longer insertion time (FUSE 6.2 min vs. standard colonoscopy 4.2 min; P< 0.001). Further analysis failed to reveal any significant difference in polyp/adenoma detection rates by lesion size or colonic section.

CONCLUSIONS

FUSE did not detect significantly more colorectal neoplasia than forward viewing colonoscopy in a medium-risk CRC screening population with positive FOBT.

International collaborative study on EUS-guided gallbladder drainage: Are we ready for prime time?

BACKGROUND

Cholecystectomy remains the gold standard treatment of cholecystitis. Endoscopic treatment of cholecystitis includes transpapillary gallbladder drainage. Recently, endoscopic ultrasound-guided transmural drainage of the gallbladder (EUS-GBD) has been reported. This study reports the cumulative experience of an international group performing EUS-GBD.

METHODS

Cases of EUS-GBD from January 2012 to November 2013 from 3 tertiary-care institutions were captured in a registry. Patient demographics, disease characteristics, procedural and clinical outcomes were recorded.

RESULTS

35 patients (15 malignant, 20 benign) were included. Median age was 81 years (SD=13.76 years), sixteen (46%) were males. Median follow-up was 91.5 days (SD=157 days). Transmural access was obtained from the stomach (n=17) or duodenum (n=18). Stents placed included plastic (n=6), metal (n=20), or combination (n=7). Technical success was achieved in 91.4% (n=32). Immediate adverse events (14%) included: bleeding, stent migration, cholecystitis and hemoperitoneum. Delayed adverse events (11%) included abscess formation and recurrence of cholecystitis. Long-term clinical success rate was 89%. Stent type and puncture site were not associated with immediate (p=0.88, p=0.62), or long-term (p=0.47, p=0.27) success.

CONCLUSIONS

EUS-GBD appears to be feasible, safe, and effective. Prospective studies are needed to confirm these findings and identify the best technique to use.

CLINICAL TRIAL REGISTRATION

NCT01522573.

International multicenter comparative trial of transluminal EUS-guided biliary drainage via hepatogastrostomy vs. choledochoduodenostomy approaches

BACKGROUND AND STUDY AIMS

Endoscopic ultrasound-guided biliary drainage (EUS-BD) can be performed entirely transgastrically (hepatogastrostomy/EUS-HG) or transduodenally (choledochoduodenostomy/EUS-CDS). It is unknown how both techniques compare. The aims of this study were to compare efficacy and safety of both techniques and identify predictors of adverse events.

PATIENTS AND METHODS

Consecutive jaundiced patients with distal malignant biliary obstruction who underwent EUS-BD at multiple international centers were included. Technical/clinical success, adverse events, stent complications, and survival were assessed.

RESULTS

A total of 121 patients underwent EUS-BD (CDS 60, HG 61). Technical success was achieved in 112 (92.56 %) patients (EUS-CDS 93.3 %, EUS-HG 91.8 %, P = 0.75). Clinical success was attained in 85.5 % of patients who underwent EUS-CDS group as compared to 82.1 % of patients who underwent EUS-HG (P = 0.64). Adverse events occurred more commonly in the EUS-HG group (19.67 % vs. 13.3 %, P = 0.37). Both plastic stenting (OR 4.95, 95 %CI 1.41 - 17.38, P = 0.01) and use of non-coaxial electrocautery (OR 3.95, 95 %CI 1.16 - 13.40, P = 0.03) were independently associated with adverse events. Length of hospital stay was significantly shorter in the CDS group (5.6 days vs. 12.7 days, P < 0.001). Mean follow-up duration was 151 ± 159 days. The 1-year stent patency probability was greater in the EUS-CDS group [0.98 (95 %CI 0.76 - 0.96) vs 0.60 (95 %CI 0.35 - 0.78)] but overall patency was not significantly different. There was no difference in median survival times between the groups (P = 0.36) CONCLUSIONS: Both EUS-CDS and EUS-HG are effective and safe techniques for the treatment of distal biliary obstruction after failed ERCP. However, CDS is associated with shorter hospital stay, improved stent patency, and fewer procedure- and stent-related complications. Metallic stents should be placed whenever feasible and non-coaxial electrocautery should be avoided when possible as plastic stenting and non-coaxial electrocautery were independently associated with occurrence of adverse events.

Utility of noninvasive ventilation in high-risk patients during endoscopic retrograde cholangiopancreatography

Background:

There is little evidence on noninvasive ventilation (NIV) preventing respiratory complications in high-risk patients undergoing endoscopy procedures.

Objectives:

The objective of this study is to demonstrate that the application of NIV through a nasal interface can prevent the appearance of ventilatory alterations during endoscopic retrograde cholangiopancreatography (ERCP) in patients with risk factors associated with the development of hypoventilation.

Patients and Methods:

A non-randomized interventional study was performed on 37 consecutive high-risk patients undergoing ERCP. During the procedure, 21 patients received oxygen by nasal cannula (3 L/minute) and sixteen received NIV through a nasal mask. Arterial blood gas analyses were conducted before and immediately after the ERCP. An Acute Physiology and Chronic Health Evaluation (APACHE) score pre-ERCP was recorded. The complications during the procedure were recorded.

Results:

The groups with and without NIV were comparable. A post-ERCP pH of <7.35 was found in eight patients, who did not receive ventilatory support (38.1%) compared to zero patients in the NIV group (P = 0.006). A post-ERCP pCO₂ >45 mmHg was found in one case (6.3%) in the NIV-group and in nine cases in the nasal cannula group (42.9%; P = 0.01). The median pCO₂ post-ERCP was lower (36.5 ± 6.2 vs. 44.5 ± 6.8 mmHg) (P = 0.001) and median pH post-ERCP was higher (7.41 ± 0.4 vs. 7.34 ± 0.5) (P = 0.001) in patients treated with NIV. In the multivariate analysis, after adjusting for gender, the APACHE score, pH and pCO₂ pre-ERCP, age, propofol doses, and procedure duration, the following differences were maintained (pCO₂ difference = 5.54, 95% Confidence Interval (CI) =2.3 – 8.7, pH difference = 0.047, and 95% CI = 0.013 – 0.081). Among the 37 procedures, four complications occurred: One in the NIV group and three in the nasal cannula group. None of them was related to NIV.

Conclusions:

Our preliminary results demonstrate that in high-risk patients undergoing ERCP, hypercapnia and respiratory acidosis are frequent. NIV prevents the appearance of these complications.

Initial experience with EUS-guided cholangiopancreatography for biliary and pancreatic duct drainage: a Spanish national survey

BACKGROUND

EUS-guided cholangiopancreatography (ESCP) allows transmural access to biliopancreatic ducts when ERCP fails. Data regarding technical details, safety, and outcomes of ESCP are still unknown.

OBJECTIVE

To evaluate outcomes of ESCP in community and referral centers at the initial development phase of this procedure, to identify the ESCP stages with higher risk of failure, and to evaluate the influence on outcomes of factors related to the endoscopist.

DESIGN

Multicenter retrospective study.

SETTING

Public health system hospitals with experience in ESCP in Spain.

PATIENTS

A total of 125 patients underwent ESCP in 19 hospitals, with an experience of <20 procedures.

INTERVENTION

ESCP.

MAIN OUTCOME MEASUREMENTS

Technical success and complication rates in the initial phase of implantation of ESCP are described. The influence of technical characteristics and endoscopist features on outcomes was analyzed.

RESULTS

A total of 125 patients from 19 hospitals were included. Biliary ESCP was performed in 106 patients and pancreatic ESCP was performed in 19. Technical success was achieved in 84 patients (67.2%) followed by clinical success in 79 (63.2%). Complications occurred in 29 patients (23.2%). Unsuccessful manipulation of the guidewire was responsible for 68.2% of technical failures, and 58.6% of complications were related to problems with the transmural fistula.

LIMITATIONS

Retrospective study.

CONCLUSION

Outcomes of ESCP during its implantation stage reached a technical success rate of 67.2%, with a complication rate of 23.2%. Intraductal manipulation of the guidewire seems to be the most difficult stage of the procedure.