Diagnosis: Coloproctology

Computer-assisted detection for CT colonography: external validation.
Halligan S, Taylor SA, Dehmeshki J, Amin H, Ye X, Tsang J, Roddie ME
Clin Radiol. 2006 Sep;61(9):758-63.

AIM: To externally validate a computer-assisted detection (CAD) system for computed tomography (CT) colonography, using data from a single centre uninvolved with the software development. MATERIALS AND METHODS: Twenty-five multi-detector CT colonography examinations of patients with validated polyps accumulated at a single centre were examined by two readers who used endoscopic and histopathological data to identify polyp coordinates. A CAD system that had been developed using data from elsewhere, and had not previously encountered the present data, was then applied to the data at sphericity filter settings of 0.75 and 0.50 and identified potential polyps. True-positive, false-negative, and false-positive counts were determined by comparison with the known polyp coordinates. RESULTS: Twenty-five patients had 57 polyps, median size 6mm (range 1-15mm). Per-patient sensitivity for the CAD system was 96% (24 of 25). The CAD system detected 44 (77%) polyps at sphericity setting 0.75 and 49 (86%) polyps at sphericity 0.50: the additional five polyps detected all measured 5mm or less. Sphericity of 0.75 resulted in a median of 10 (one to 34) easily dismissed false-positive prompts per patient and a median of 4 (zero to 15) that needed three-dimensional rendering before dismissal. This rose to 32 (16 to 99) and 11 (three to 35), respectively, at sphericity 0.5. CONCLUSIONS: A per-patient sensitivity of 96% was found for the CAD system (in patients with a median polyp diameter of 6mm) using external validation, a more stringent test than either internal cross-validation or temporal validation. Decreasing sphericity increases sensitivity for small polyps at the expense of decreased specificity.

Re: Three-dimensional transperineal ultrasonography for evaluation of the anal sphincter complex: another dimension in understanding peripartum sphincter trauma.
Grasso RF, Piciucchi S, Quattrocchi CC, Beomonte Zobel B
Ultrasound Obstet Gynecol. 2006 Sep;28(3):353-4.

Magnetic resonance imaging measurement of the anorectal striated muscle complex in normal children.
Tang S, Tong Q, Mao Y, Wang Y, Li S, Cao Z, Ruan Q
J Pediatr Surg. 2006 Sep;41(9):1549-55.

PURPOSE: The aim of the study was to describe and establish a normal measurement of the striated muscle complex (SMC) in healthy children using body phased-array or head coil magnetic resonance imaging. METHODS: Imaging was performed in 20 boys and 20 girls (age range, from 3 months to 14 years; average age, 3.2 years) without anorectal disorders. The dimensions of the puborectalis muscle (PR) and external anal sphincter (EAS) were measured in different planes. RESULTS: There was a close positive correlation between absolute width and length of SMC and age (P < .05), whereas there was no correlation between the relative width and length of SMC and age (P > .05). Normal relative length of the PR and EAS were measured as 0.47 +/- 0.04 and 0.41 +/- 0.04, respectively, and the normal relative width of PR and posterior EAS were 0.50 +/- 0.04 and 0.44 +/- 0.04 in children younger than 14 years. CONCLUSIONS: The width and length of PR and EAS increase progressively with age. The relative width and length of PR and EAS were not variable with age. A relative width and length of PR and EAS were chosen as objective criteria for normal SMC in children younger than 14 years.

July

ACG colorectal cancer prevention action plan: update on CT-colonography.
Rex DK, Lieberman D
Am J Gastroenterol. 2006 Jul;101(7):1410-3.

Screening Colonoscopy Use Among Individuals at Higher Colorectal Cancer Risk.
Longacre AV, Cramer LD, Gross CP
J Clin Gastroenterol. 2006 Jul;40(6):490-496.

GOALS: To describe screening colonoscopy use in those with a family history of colorectal cancer (CRC). BACKGROUND: Colonoscopy is an effective means of screening for CRC and is preferred for individuals at higher risk. We therefore derived population-based estimates of colonoscopy use and analyzed how individual characteristics and family history correlate with colonoscopy. STUDY: Individuals between the ages of 41 and 75 years who responded to the Cancer Control Module of the 2000 National Health Interview Study were analyzed. Screening colonoscopy was defined as having a colonoscopy for screening purposes within the last 10 years. Screening colonoscopy was the dependent variable and family history was the independent variable in a logistic regression model that included self-described sociodemographic characteristics. RESULTS: Of the 13,160 individuals in the analysis, 6.8% had a family history of CRC, corresponding to approximately 5.5 million individuals in the United States. Those with a family history were significantly more likely to report screening colonoscopy (27.8%) than those without a family history (7.7%; P<0.001). In those with a family history, screening colonoscopy significantly correlated with tobacco use, education, and age. There was no trend for increased screening colonoscopy with having multiple family members or a young family member with CRC. CONCLUSIONS: Over 5.5 million people in the US have a family history of CRC, and only 1 in 4 report having had a screening colonoscopy by the year 2000. Improving knowledge about CRC and addressing other barriers to screening in this group will be important components of improving screening colonoscopy utilization.

June

[Colo and enteroscanner]
Otal P, Canevet G, Chabbert V, Lannareix V, Rousseau H, Joffre F
Gastroenterol Clin Biol. 2006 May;30(5):732-6.

Gastrointestinal endoscopes cleaned without detergent substance following an automated endoscope washer/disinfector dysfunction.
Mean M, Mallaret MR, Bichard P, Shum J, Zarski JP
Gastroenterol Clin Biol. 2006 May;30(5):665-8.

OBJECTIVE: To report cases of gastrointestinal endoscopies performed with endoscopes that were reprocessed without detergent substance during a period of dysfunction of the automated endoscope reprocessor (AER). METHOD: A dysfunction of the AER for the cycles requiring detergent substance was reported at the Grenoble University Hospital on March 2005. During this period, 72 patients had potentially been exposed to a contaminated endoscope. A recall procedure was organized and serologic tests (HIV, HCV, HBV) were performed 3 and 6 months after the AER incident. RESULTS: Within the 72 patients convened, 56 (77.8%) were seen in consultation and accepted the serologic screening. Finally, serologic screening was done for 59 patients (81.9%) and no seroconversion for HIV, HCV, or HBV was observed. The final attrition rate was 13 patients (18.1%). CONCLUSION: No viral infection was transmitted during the AER dysfunction. After this AER incident, the monitoring of the endoscopic procedures and the traceability of the cleaning process were both improved to prevent further incidents.

Immediate endoscopic closure of colon perforation by using a prototype endoscopic suturing device: feasibility and outcome in a porcine model (with video).
Pham BV, Raju GS, Ahmed I, Brining D, Chung S, Cotton P, Gostout CJ, Hawes RH, Kalloo AN, Kantsevoy SV, Pasricha PJ
Gastrointest Endosc. 2006 Jul;64(1):113-9.

BACKGROUND: Perforation is an uncommon but potentially devastating complication of colonoscopy. Surgical closure is the standard of care. Immediate endoluminal closure of a perforation would avoid the morbidity and mortality associated with general anesthesia, laparotomy, and surgical repair. OBJECTIVES: To evaluate the feasibility and safety of full-thickness endoscopic closure of colonic perforations with a prototype endoscopic suturing device, the Eagle Claw, in a porcine model. DESIGN: Endoscopic animal experimental study of closure of colon perforation by using a porcine model. SUBJECTS: Ten pigs were included in the study. INTERVENTIONS: The Eagle Claw was used to close small perforations (1.5 to 2 cm) of the colon created by needle-knife with the animal under general anesthesia by using the endoluminal route. All animals received intravenous antibiotics and were allowed to eat after 24 hours. MAIN OUTCOME MEASUREMENTS: The animals were monitored daily for signs of sepsis and peritonitis. On day 7, they were euthanized. The peritoneal cavity was examined for fecal peritonitis, and the colon perforation site was checked for wound dehiscence and pericolic abscess formation. RESULTS: Endoscopic closure of the colon perforation was successful in 7 animals, and they recovered well without any sepsis or peritonitis. Necropsy did not reveal fecal peritonitis or pericolonic abscess formation at the site of perforation, and the perforation healed well. Closure was successful in 1 animal, but necropsy revealed dehiscence of the colon perforation site. Endoscopic closure was unsuccessful in 2 animals, and these were euthanized immediately. CONCLUSIONS: Closure of acute perforation of the colon is feasible with the Eagle Claw endoscopic suturing device in a porcine model.

The genome is now accessible to the endoscopist.
Lowe AW
Gastrointest Endosc. 2006 Jul;64(1):27-8.

Less patient discomfort by one-man colonoscopy examination.
Lee IL, Wu CS
Int J Clin Pract. 2006 Jun;60(6):635-8.

A randomised prospective trial compared safety and patient tolerance for one-man method with two-man method undergoing colonoscopy. Eighty patients were randomized to 1 of 2 groups: the two-man method group (n = 40); or the one-man method group (n = 40). All colonoscopic examinations were performed by the same endoscopist to reduce skill-based variation. Patient tolerance for colonoscopy was evaluated with a numerical rating scale ranging from 0 for painless to 5 for maximal pain. Cardiopulmonary parameters were recorded during the procedure. Patients receiving one-man method had lower pain score than two-man method. The length of the scope reach to the cecum was shorter in the one-man group than the two-man group. The patients underwent two-man colonoscopy had higher maximum increase in heart rate during the procedure compared with one-man group. One-man colonoscopy can improve patient tolerance and reduces patient pain by decreasing the redundancy of colonoscope during the procedure.

One man and his scope.
Parkes GC, Sanderson JD
Int J Clin Pract. 2006 Jun;60(6):633-4.

Validation of a semi-automated scintigraphic technique for detecting episodic, real-time colonic flow.
Dinning PG, McKay E, Cook IJ
Neurogastroenterol Motil. 2006 Jul;18(7):547-55.

The relationships between the movement of colonic content and regional pressures have only been partially defined. During the analysis of a combined colonic scintigraphic and manometric study, a quantitative technique for determining discrete, episodic, real-time colonic flow was developed. Our aim was to validate this technique through the construction of a computer-generated phantom model of known antegrade and retrograde motility. The anthropoid phantom was rasterized into a 6-mm voxel model to create a 3D voxel phantom of the colon with four distinct colonic segments. Associating a time/activity curve with each segment simulated dynamic behaviour. Activity in the model was based on data obtained from human colonic scintigraphic recordings using 30 MBq of (99m)Tc sulphur colloid. The flow was simulated by modifying the input time/activity functions to represent episodes of net flow of 2%, 5% or 10% of segmental content. Our quantitative technique was applied to the phantom model to measure the accuracy with which simulated flows were detected. Our quantitative technique proved to be a sensitive and specific means of detecting the presence and the magnitude of discrete episodes of colonic flow and therefore, should improve our ability to correlate colonic flow and motor patterns.

Inappropriate and improper use of fecal occult blood tests for colorectal cancer screening in the VA Medical System.
Ahmed F, Murthy UK
Am J Gastroenterol. 2006 Jun;101(6):1401.

Screening for colorectal cancer with flexible sigmoidoscopy: is a 5-yr interval appropriate? A comparison of the detection of neoplasia 3 yr versus 5 yr after a normal examination.
Burke CA, Elder K, Lopez R
Am J Gastroenterol. 2006 Jun;101(6):1329-32.

CONTEXT: The recommended interval for colorectal cancer screening with flexible sigmoidoscopy (FS) was recently lengthened from 3 to 5 yr. Direct evidence supporting the longer interval is lacking. The appropriateness of the longer interval has been questioned. OBJECTIVE: To compare the incidence of neoplasia detected on FS in individuals who had undergone an FS either 3 yr or 5 yr after a normal examination. DESIGN, SETTINGS, AND PATIENTS: Subjects were drawn from 5,359 individuals who underwent two FS examinations performed for colorectal cancer screening. Examinations were performed by gastroenterologists at a single academic medical center between 1987 and 2002. A total of 2,146 subjects with a normal baseline examination and a follow-up examination 3 and 5 yr later was included. MAIN OUTCOME MEASURE: To compare the incidence of neoplasia, including advanced neoplasia, detected 3 yr versus 5 yr after a normal FS. RESULTS: 915 subjects underwent FS at 3 yr and 1,231 subjects at 5 yr after a normal examination. Neoplasia was detected in 3.2% of the 3-yr and 4.3% of the 5-yr subjects (p=0.17). No significant differences were detected in the pathology, multiplicity, or size of neoplasms between the 3- and 5-yr groups. Advanced neoplasms occurred in 0.9% (including one adenocarcinoma) of subjects at 3 yr and 1.1% of subjects at 5 yr (p=0.67). CONCLUSIONS: Few individuals will develop rectosigmoid neoplasms 3 or 5 yr after a normal FS. The majority of neoplasms detected are low-risk lesions. A screening interval of 5 yr after a normal FS does not portend an increased risk of advanced neoplasms including cancer. This direct evidence supports the current recommendations of a 5-yr interval for colorectal cancer screening with FS.

A randomized controlled trial comparing the accuracy of general diagnostic upper gastrointestinal endoscopy performed by nurse or medical endoscopists.
Meaden C, Joshi M, Hollis S, Higham A, Lynch D
Endoscopy. 2006 Jun;38(6):553-60.

BACKGROUND AND STUDY AIMS: Rising demand for general diagnostic upper gastrointestinal endoscopy in the UK is outgrowing the capacity of doctors to provide this service within a reasonable time. One solution is to train nurses to carry out the procedure, but it is not known whether nurses can perform general diagnostic upper gastrointestinal endoscopy as competently as doctors. PATIENTS AND METHODS: A randomized controlled non-inferiority trial compared the adequacy and the accuracy of diagnostic upper gastrointestinal endoscopies performed by five medical and two nurse endoscopists. The videotaped procedures were assessed by a consultant gastroenterologist blinded to the identity of the endoscopist. RESULTS: 641 patients were randomly allocated (before attendance and consent procedure) to endoscopy carried out either by a doctor or a nurse. Of these, 412 were enrolled and 367 (89 %) were included in the analysis. An adequate view was obtained throughout in 53.4 % (93/177) of doctor endoscopies and 91.6 % (174/190) of nurse endoscopies (difference 38.2 %, 95 % CL 30.5 %, 47.2 %). In adequately viewed areas, the mean agreement between doctor and expert was 81.0 % and between nurse and expert it was 78.3 % (difference between the means 2.7 %, 95 % CL - 1.0 %, 6.4 %). There was no difference between doctors and nurses in the rate of biopsy performance (90.4 % and 91.1 %, respectively, P = 0.862). Nurses took longer (8.1 minutes vs. 4.6 minutes, P < 0.001) and used intravenous sedation more often (57.6 %, P = 0.027). Adequacy of view correlated positively with endoscopy duration ( P < 0.001), but diagnostic accuracy correlated inversely with duration ( P < 0.001). Neither adequacy or accuracy correlated significantly with use of intravenous sedation. CONCLUSIONS: In endoscopies performed by nurses, the proportion of adequate examinations was much higher than that found for doctors. In areas with an adequate view, there is no significant difference in accuracy between nurses and doctors. Nurses can provide an accurate general diagnostic upper gastrointestinal endoscopy service as competently as doctors.

May

Anal Manometry: A Comparison of Techniques.
Simpson RR, Kennedy ML, Nguyen MH, Dinning PG, Lubowski DZ
Dis Colon Rectum. 2006 May 29;.

PURPOSE: Methods of anal manometry vary between centers, resulting in potential difficulties in interpretation of results. This study compared several accepted manometric techniques in healthy control subjects and in patients with fecal incontinence. METHODS: Eleven patients with fecal incontinence (M:F = 3:8; mean age = 67 years) and ten healthy control subjects (M:F = 3:7; mean age = 64 years) underwent anal manometry using five different methods: 1) water-perfused side hole; 2) water-perfused end hole; 3) microtransducer; 4) microballoon; 5) portable Peritron. Using a station pull-through technique, anal pressures (resting, squeeze, and cough pressures) were recorded at 1-cm intervals from rectum to anal verge, as well as radial pressures in four quadrants for Methods 1 and 2. RESULTS: Water perfusion side hole recorded slightly higher maximal resting pressures; however, there were no significant differences between any of the methods. In healthy control subjects, distal maximal squeeze pressures were significantly higher (P < 0.05) than proximally as measured by microtransducer. There were slight (nonsignificant) variations in radial pressures with water perfusion and microtransducer. Peritron values for maximum resting pressure and maximum squeeze pressure were lower than those recorded by water perfusion side hole by a factor of 0.8. CONCLUSIONS: There is no significant variation in anal pressure recordings using standard manometry techniques. Variations in radial pressures are slight and not significant in clinical studies. Results obtained with portable nonperfusion systems must be interpreted appropriately.

Measurement of the Anal Cushions by Transvaginal Ultrasonography.
Nicholls MJ, Dunham R, O'herlihy S, Finan PJ, Sagar PM, Burke D
Dis Colon Rectum. 2006 May 29;.

PURPOSE: The anal cushions are believed to contribute to the anal continence mechanism. Transvaginal ultrasound previously has been used to visualize the anal sphincters. Using this method, visualization of the anal cushions has been described but no quantitation of the cushions has been undertaken. Because impairment of the anal cushion function may lead to anal incontinence, this study was designed to evaluate the use of transvaginal ultrasound to measure the anal cushions. METHODS: Patients attending a gynecologic ultrasound list were recruited into the study. By measuring cross-sectional areas, a cushion:canal ratio was calculated. RESULTS: Fifty females were studied. Results showed that the area enclosed within the internal anal sphincter had a median of 2.37 cm(2) (interquartile range, 1.76-2.61). The cushion:canal ratio was 0.66 (interquartile range, 0.57-0.7). Interobserver error was 0.98 and intraobserver error 0.99. CONCLUSIONS: In this pilot study, we conclude that transvaginal ultrasonography is a reliable method of measuring the anal cushions in healthy control subjects. A narrow normal range can be established. This may be compared later with anal cushion size in patients who have symptoms of incontinence and may be used to assess changes in the size of the cushions in response to recently described anal cushion bulking agents.

A New Method of Assessing Anal Sphincter Integrity Using Inverted Vectormanometry.
Kaur G, Gardiner A, Duthie GS
Dis Colon Rectum. 2006 May 19;.

PURPOSE: Vectorgraphy as an integrated mapping of radial pressure profiles of the anal canal has been used to attempt identification of pressure-related defects with doubtful reliability since vectorgraphs bear no resemblance to endoanal ultrasound scans at similar levels in the anal canal. This study aimed to devise a technique to enable vectorgraphy to be more representative of sphincter function and integrity. METHODS: Vectormanometry was performed in 50 patients with anorectal disorders using an Arndorfer pneumohydraulic system. "Normal" three-dimensional manometric images of each 0.5 cm of the anal sphincter were computer-generated by plotting anal pressures at rest and during squeeze radially around a central zero axis. The graphs were replotted with zero at the periphery and maximal anal pressure at the center. Both this ("inverted") and "normal" vectorgraphs were compared with endoanal ultrasound images at similar levels, assessing both internal and external anal sphincters. RESULTS: Standard vectormanometry produced excellent pictures of pressures throughout the anal canal; the anatomy however bore no resemblance to the pictures produced by endoanal ultrasound. The inverted vectographs showed a much better correlation with endoanal ultrasound at each 0.5-mm level of the anal canal, for both squeeze pressure graphs and external sphincter correlations and for resting pressure graphs and internal sphincter correlations. CONCLUSIONS: Accurate assessment of sphincter integrity is not possible when interpreting the vectormanometry graphs in the current format; however, inverted vectorgraphy gives good correlations with endoanal ultrasound and provides combined functional (pressure measurement) and anatomic (three-dimensional profile) information regarding the anal canal.

Fecal occult blood testing: Forget the finger!
Mishkin DS, Schroy PC 3rd
Gastroenterology. 2005 Jul;129(1):384-6.

April

Advice for optimizing colonic distention and minimizing risk of perforation during CT colonography.
Dachman AH
Radiology. 2006 May;239(2):317-21.

Visuospatial Abilities Correlate With Performance of Senior Endoscopy Specialist in Simulated Colonoscopy.
Westman B, Ritter EM, Kjellin A, Torkvist L, Wredmark T, Fellander-Tsai L, Enochsson L
J Gastrointest Surg. 2006 Apr;10(4):593-599.

Visuospatial abilities have been demonstrated to predict the performance of medical students in simulated endoscopy. However, little has been reported whether differences in visuospatial abilities influence the performance of senior endoscopists or whether their vast endoscopy experience reduces the importance of these abilities. Eleven senior endoscopists were included in our study. Before the simulated endoscopies in GI Mentor II (gastroscopy: case 3, module 1 and colonoscopy: case 3, module 1), the endoscopists performed three visuospatial tests: (1) pictorial surface orientation (PicSOr), (2) card rotation, and (3) cube comparison tests that monitor the ability of the tested person to re-create a three-dimensional image from a two-dimensional presentation as well as mentally manipulate that re-created image. The results of the visuospatial tests were correlated to the performance parameters of the virtual-reality endoscopy simulator. The percent of time spent with clear view in the simulated colonoscopy correlated well with the performance in the visuospatial PicSOr (r = -0.75, P = 0.01), card rotation (r = 0.75, P = 0.01), and cube comparison (r = 0.79, P = 0.004) tests. The endoscopists who performed better in the visuospatial tests also were better at maintaining visualization of the colon lumen. Those who performed better in the PicSOr test formed fewer loops during colonoscopy (r = 0.60, P = 0.05). In the technically less demanding simulated gastroscopy, there were no such correlations. The visuospatial tests performed better in endoscopists not playing computer games. Good visuospatial ability correlates significantly with the performance of experienced endoscopists in a technically demanding simulated colonoscopy, but not in the less demanding simulated gastroscopy.

Assessment of patient satisfaction with endoscopy using an interactive voice response system.
Altman C, Birraux T, Lapuelle J, Letard JC, Tusseau F, Canard JM
Gastroenterol Clin Biol. 2006 Mar;30(3):371-6.

AIM: The aim of this study was to determine the feasibility of patient's satisfaction assessment after endoscopy using an interactive voice response (IVR) system.METHODS: A specific IVR system was developed for this study and proposed to patients by 161 private gastroenterologists after an endoscopic procedure. No reminder was used for the patients not calling spontaneously the IVR.RESULTS: After endoscopy, 31% of the patients called the IVR and 1052 answered the entire questionnaire. The answers obtained by the IVR and a face-to-face interview were concordant for 98.8% of the questions. The endoscopy was carried out with anesthesia for 94% of the patients and 95% stated they would agree to undergo the procedure again under the same conditions. This was independently associated with the presence of explanations about the procedure before its realization, male gender and, for the patients having had a colonoscopy, difficulties in taking the bowel cleaner and the presence of pain after the colonoscopyCONCLUSION: This study shows the feasibility of patient's satisfaction assessment with endoscopy using an IVR system under routine conditions of endoscopy practice.

Incidence of colonic perforation at CT colonography: review of existing data and implications for screening of asymptomatic adults.
Pickhardt PJ
Radiology. 2006 May;239(2):313-6.

The Norwegian Gastronet project: Continuous quality improvement of colonoscopy in 14 Norwegian centres.
Hoff G, Bretthauer M, Huppertz-Hauss G, Kittang E, Stallemo A, Hoie O, Dahler S, Nyhus S, Halvorsen FA, Pallenschat J, Vetvik K, Kristian Sandvei P, Friestad J, Pytte R, Coll P
Scand J Gastroenterol. 2006 Apr;41(4):481-7.

OBJECTIVE: The burden on colonoscopy capacity is considerable and expected to increase further as colorectal cancer screening programmes gain a foothold in Europe. In this situation, it is particularly important to evaluate the quality of the service given. In this article we present our first year of experience with a quality network of endoscopy centres in Norway (Gastronet). MATERIAL AND METHODS: A questionnaire focusing on caecal intubation rate and pain was completed by the endoscopist (on site) and patient (on the day after the examination). Fourteen centres participated with registration of 7370 colonoscopies by 73 endoscopists. RESULTS: There was 100% endoscopist participation, 87% coverage of colonoscopies and an estimated 76% questionnaire coverage of the patient population. Overall caecal intubation rate was 91%, range 83% to 97% between centres (p < 0.001). Patients reporting severe pain during colonoscopy differed from 2 to 24% between centres (p < 0.001). Variations could only partly be explained by differences in procedure practice (sedation, CO2 insufflation). For individual endoscopists, improvement after feedback on performance was restricted to the group of endoscopists having contributed with only 50-99 registered colonoscopies. CONCLUSIONS: In quality assurance programmes we recommend a limited number of variables for registration in order to secure high compliance by endoscopists and patients. One year of experience with Gastronet disclosed a satisfactory overall caecal intubation rate, but considerable variation between centres in practice and ability to offer painless colonoscopy. This suggests a need for formal, centralized training of colonoscopists or the development of quality standards for colonoscopy training and practice.

March

Polyp Detection with CT Colonography: Primary 3D Endoluminal Analysis versus Primary 2D Transverse Analysis with Computer-assisted Reader Software.
Taylor SA, Halligan S, Slater A, Goh V, Burling DN, Roddie ME, Honeyfield L, McQuillan J, Amin H, Dehmeshki J
Radiology. 2006 Mar 16;.

Purpose: To retrospectively compare primary three-dimensional (3D) endoluminal analysis with primary two-dimensional (2D) transverse analysis supplemented by computer-assisted reader (CAR) software for computed tomographic (CT) polyp detection and reader reporting times. Materials and Methods: Ethical permission and patient consent were obtained from all donor institutions for use of CT colonography data sets. Twenty CT colonography data sets from 14 men (median age, 61 years; age range, 52-78 years) with 48 endoscopically proved polyps were selected. Polyp coordinates were documented in consensus by three unblinded radiologists to create a reference standard. Two radiologists read the data sets, which were randomized between primary 3D endoluminal views with 2D problem solving and 2D views supplemented by CAR software. Reading times and diagnostic confidence were documented. The CAR software highlighted possible polyps by superimposing circles on the 2D transverse images. Data sets were reread after 1 month by using the opposing analysis method. Detection rates were compared by using the McNemar test. Reporting times and diagnostic confidence were compared by using the paired t test and Mann-Whitney U test, respectively. Results: Mean sensitivity values for polyps measuring 1-5, 6-9, and 10 mm or larger were 14%, 53%, and 83%, respectively, for 2D CAR analysis and 16%, 53%, and 67%, respectively, for primary 3D analysis. Overall sensitivity values were 41% for 2D CAR analysis and 39% for primary 3D analysis (P = .77). Reader 1 detected more polyps than reader 2, particularly when using the 3D fly-through method (P = .002). Mean reading times were significantly longer with the 3D method (P = .001). Mean false-positive findings were 1.5 for 2D analysis and 5.5 for 3D analysis. Reader confidence was not significantly different between analysis methods (P = .42). Conclusion: Two-dimensional CAR analysis is quicker and at least matches the sensitivity of primary 3D endoluminal analysis, with fewer false-positive findings. (c) RSNA, 2006.

Water enema computed tomography: diagnostic tool in suspicion of colorectal tumor.
Pilleul F, Bansac-Lamblin A, Monneuse O, Dumortier J, Milot L, Valette PJ
Gastroenterol Clin Biol. 2006 Feb;30(2):231-4.

OBJECTIVES: The aim of this study was to assess the accuracy of water enema multi-row computed tomography for detecting clinically suspected colorectal tumor. PATIENTS AND METHODS: A water enema multi-row computed tomography (WE-MR-CT) was performed in 128 consecutive patients (71 women, mean age 67.7 years) referred for suspicion of colorectal cancer. We defined at least one centimeter size of the lesion as the threshold of detection. The results of WE-MR-CT were compared with the diagnosis obtained by colonoscopy, pathology or clinical follow-up. RESULTS: The overall sensitivity and specificity of water enema multi-row CT in identifying patients with colorectal lesions were 95.5% and 93.5%, respectively. The negative predictive value was 98.8% for a 10-mm threshold lesion size. WE-MR-CT allowed identifying synchronous lesions in three cases. CONCLUSIONS: WE-MR-CT can accurately detect supracentimetric colorectal tumors. The performance of this technique should be further evaluated in prospective studies.

Colonic manometry as predictor of cecostomy success in children with defecation disorders.
van den Berg MM, Hogan M, Caniano DA, Di Lorenzo C, Benninga MA, Mousa HM
J Pediatr Surg. 2006 Apr;41(4):730-6; discussion 730-6.

PURPOSE: The aim of this study was to define the predictive value of colonic manometry and contrast enema before cecostomy placement in children with defecation disorders. METHODS: Medical records, contrast enema, and colonic manometry studies were reviewed for 32 children with defecation disorders who underwent cecostomy placement between 1999 and 2004. Diagnoses included idiopathic constipation (n = 13), Hirschsprung's disease (n = 2), cerebral palsy (n = 1), imperforate anus (n = 6), spinal abnormality (n = 6), and anal with spinal abnormality (n = 4). Contrast enemas were evaluated for the presence of anatomic abnormalities and the degree of colonic dilatation. Colonic manometry was considered normal when high-amplitude propagating contractions (HAPC) occurred from proximal to distal colon. Clinical success was defined as normal defecation frequency with no or occasional fecal incontinence. RESULTS: Colonic manometry was done on 32 and contrast enema on 24 patients before cecostomy. At follow-up, 25 patients (78%) fulfilled the success criteria. Absence of HAPC throughout the colon was related to unsuccessful outcome (P = .03). Colonic response with normal HAPC after bisacodyl administration was predictive of success (P = .03). Presence of colonic dilatation was not associated with colonic dysmotility. CONCLUSION: Colonic manometry is helpful in predicting the outcome after cecostomy. Patients with generalized colonic dysmotility are less likely to benefit from use of antegrade enemas via cecostomy. Normal colonic response to bisacodyl predicts favorable outcome.

An analysis of proctoscopy vs computed tomography scanning in the diagnosis of rectal injuries in children: which is better?
Leaphart CL, Danko M, Cassidy L, Gaines B, Hackam DJ
J Pediatr Surg. 2006 Apr;41(4):700-3; discussion 700-3.

BACKGROUND: Current dogma suggests that the diagnosis of rectal injury can be made after physical examination and proctoscopy (PR). However, anecdotal evidence suggests that these modalities lack specificity when applied to children and that computed tomography (CT) scanning may be superior. A direct comparison between CT scanning and PR has not been performed. We therefore sought to compare CT with PR in the diagnosis of rectal injury by analyzing our large institutional experience. METHODS: To assess institutional outcome, the charts of all children younger than 18 years admitted to our level I trauma center (1999-2004) were prospectively collected and retrospectively assessed. Demographics, diagnostic accuracy (PR vs CT), and outcome (length of stay, days in the intensive care unit [ICU], Injury Severity Score, and missed injury) were assessed. RESULTS: There were 24 injuries (63% boys, 71% blunt, 100% survival), and diagnostic modality included the following: PR, 37.5%; CT, 37.5%; laparotomy alone, 8%. Length of stay (PR 5.7 +/- 6.2 vs CT 13.7 +/- 22.2, NS) were similar between groups. Of the missed rectal injuries, 66% of patients undergoing PR had missed injuries that were ultimately detected by CT whereas 33% of the patients undergoing CT scan had a missed injury. CONCLUSION: CT is at least as accurate as PR in diagnosing pediatric rectal injury. Consideration of early scanning as opposed to PR may improve diagnosis and outcome in these patients.

Endoscopic Sedation in the United States: Results from a Nationwide Survey.
Cohen LB, Wecsler JS, Gaetano JN, Benson AA, Miller KM, Durkalski V, Aisenberg J
Am J Gastroenterol. 2006 Mar 30;.

OBJECTIVES: The introduction of new sedative agents as well as a desire for improved patient satisfaction and greater efficiency has changed the practice of endoscopic sedation. This survey was designed to provide national and regional data on endoscopic sedation and monitoring practices within the United States. METHODS: A 22-item survey regarding current practices of endoscopy and sedation was mailed to 5,000 American College of Gastroenterology physician members nationwide. RESULTS: A total of 1,353 questionnaires (27.1%) were returned. Respondents performed an average of 12.3 esophagogastroduodenoscopies (EGDs) and 22.3 colonoscopies per wk. Endoscopic procedures were performed within a hospital setting (55.2) more often than at an ambulatory center (35.8%) or private office (8.8%). The vast majority of EGDs and colonoscopies (>98%) were performed with endoscopic sedation. Almost three quarters (74.3%) of the respondents used a narcotic and benzodiazepine for sedation, while propofol was preferred by 25.7%. Sedation practices varied considerably within different geographic regions of the United States. Respondents routinely monitored vital signs and pulse oximetry (99.2% and 98.6%, respectively), and supplemental oxygen was administered to all patients during EGD by 72.7% of endoscopists. Endoscopist satisfaction with sedation was greater among those using propofol than conventional sedation (10 vs 8, p < 0.0001). CONCLUSIONS: During the past 15 yr, the volume of procedures performed by endoscopists in the United States has increased two- to fourfold. Propofol is currently being used for sedation in approximately one quarter of all endoscopies in the United States. The findings from this survey may help in the formulation of updated policies and practice guidelines pertaining to endoscopic sedation.

Impending or pending? The national bowel cancer screening programme.
Atkin WS
BMJ. 2006 Apr 1;332(7544):742. Epub 2006 Mar 22.

Review in depth and meta-analysis of controlled trials on colorectal cancer screening by faecal occult blood test.
Heresbach D, Manfredi S, D'halluin PN, Bretagne JF, Branger B
Eur J Gastroenterol Hepatol. 2006 Apr;18(4):427-433.

BACKGROUND: Several randomized studies have shown that colorectal cancer (CRC) screening by faecal occult blood test (FOBT) reduces CRC mortality. These trials have different designs, especially concerning FOBT frequency and duration, as well as the length of follow-up after stopping FOBT campaigns. AIMS: To review the effectiveness of screening for CRC with FOBT, to consider the reduction in mortality during or after screening or to identify factors associated with a significant mortality reduction. METHODS: A systematic review of trials of FOBT screening with a meta-analysis of four controlled trials selected for their biennial and population-based design. The main outcome measurements were mortality relative risk (RR) and 95% confidence interval (CI) of biennial FOBT during short (10 years, i.e. five or six rounds) or long-term (six or more rounds) screening periods, as well as after stopping screening and follow-up during 5-7 years. The meta-analysis used the Mantel-Haenszel method with fixed effects when the heterogeneity test was not significant, and used 'intent to screen' results. RESULTS: Although the quality of the four trials was high, only three were randomized, and one used rehydrated biennial FOBT associated with a high colonoscopy rate (28%). A meta-analysis of mortality results showed that subjects allocated to screening had a reduction of CRC mortality during a 10-year period (RR 0.86; CI 0.79-0.94) although CRC mortality was not decreased during the 5-7 years after the 10-year (six rounds) screening period, nor in the last phase (8-16 years after the onset of screening) of a long-term (16 years or nine rounds) biennial screening. Whatever the design of the period of ongoing FOBT, CRC incidence neither decreased nor increased, although it was reduced for 5-7 years after the 10-year screening period. Neither the design nor the clinical or demographic parameters of these trials were independently associated with CRC mortality reduction. CONCLUSION: Biennial FOBT decreased CRC mortality by 14% when performed over 10 years, without evidence-based benefit on CRC mortality when performed over a longer period. No independent predictors of CRC mortality reduction have been identified in order to allow a CRC screening programme in any subgroups of subjects at risk.

The role of scintigraphic defecography in the assessment of bowel function after restorative proctocolectomy for ulcerative colitis.
Selvaggi F, Cuocolo A, Giuliani A, Sciaudone G, Riegler G, Mainolfi C, Caprio MG, Panico MR, Fiume I
Int J Colorectal Dis. 2006 Mar 24;.

BACKGROUND: The aim of the study was to evaluate the efficiency of defecation in patients with ileal pouch for ulcerative colitis by using the mean of scintigraphic defecography. METHODS: Sixteen patients were classified into two groups according to the presence of good (group A) or poor (group B) pouch function. Emptying efficiency was calculated by scintigraphic defecography and measured as percentage of evacuation. This involves the use of up to 200 ml of an artificial stool made up of methyl cellulose paste labeled with 180 MBq of technetium-99 m (Tc-99 m) methylene diphosphonate. Potential causes of increased frequency in the absence of additional associated symptoms of dysfunction were excluded in all patients. Maximum tolerated volume (MTV) and balloon expulsion tests were also performed on all patients. RESULTS: No patient in both groups showed evidence of organic pouch dysfunction. Percentage of emptying was higher in patients of group A (n=6) than in group B (n=10) (81+/-9 vs 71+/-9%, respectively, P<0.05; correlation, -0.51, P<0.04). Mean MTV was similar in the two groups (group A: 361+/-118 ml and group B: 338+/-77 ml, P=0.7). Results of the balloon expulsion test were normal in all patients except for one individual in group B. CONCLUSION: In patients with ileal pouch for ulcerative colitis, increased frequency of defecation without any evidence of pouch dysfunction may be correlated with an alteration of emptying efficiency. Scintigraphic defecography is appropriate to use for investigation of this condition with no disadvantages for the patients.

Flexible Sigmoidoscopy Performed by Nurses.
Goodfellow PB
Endoscopy. 2006 Feb 3;.

Projected national impact of colorectal cancer screening on clinical and economic outcomes and health services demand.
Zarchy T
Gastroenterology. 2006 Mar;130(3):1012; author reply 1012.

A novel model used to compare water-perfused and solid-state anorectal manometry.
Florisson JM, Coolen JC, Bissett IP, Plank LD, Parry BR, Menzi E, Merrie AE
Tech Coloproctol. 2006 Mar 15;.

BACKGROUND: Anal pressures are commonly measured using water-perfused and solid-state manometers. We constructed a dynamic model of the anus to compare the agreement and reproducibility of the two types of manometers. METHODS: The model system was constructed using a pig anorectum together with an inflatable bowel sphincter. The pig anorectum was mounted on a jig and the sphincter was inserted external to the internal sphincter. The sphincter pressure was adjusted over the range 20 to 185 mmHg. At each of 24 constant sphincter pressures, triplicate readings were carried out with both manometers. The first measurement by each method was used for the comparison. The replicate measurements were used to calculate measures of repeatability for each method. RESULTS: Measurements by the two manometers were highly correlated (r=0.97). Measurements by the solid state manometer were higher than the water-perfused manometer by 8.1+/-12.2 mmHg (mean+/-SD). Precision (coefficient of variation) for the solid-state manometer (2.8%) was better than for the water-perfused manometer (8.3%). CONCLUSIONS: The new model of the anal canal shows promise as a tool for assessing physiological interventions. The solid-state manometer has many advantages over the water-perfused manometer, providing more consistent measurements at clinically relevant pressures.

An evaluation of the American College of Surgeons' ultrasound education program.
Staren ED, Knudson MM, Rozycki GS, Harness JK, Wherry DC, Shackford SR
Am J Surg. 2006 Apr;191(4):489-96.

BACKGROUND: Ultrasound has a wide variety of applications in surgery, but until recently few surgeons received any formal training in its use. To facilitate incorporation of ultrasound into surgical practice, the American College of Surgeons (ACoS) developed an ultrasound educational program. The purpose of this study was to evaluate the impact and effectiveness of the ACoS ultrasound education program. METHODS: A survey was mailed to all surgeons who had completed at least one of several ultrasound courses offered by the ACoS from 1998 to 2002. RESULTS: A total of 1,791 surveys were mailed out and 873 completed surveys were returned. Sixty-five percent (576) of respondents reported using ultrasound in their practices after these educational courses. Of those performing ultrasound examinations, 267 did so in one clinical area and 309 in more than one. The most common examination was breast (369 surgeons); vascular, acute/trauma, abdominal, intraoperative/laparoscopic, and head/neck were utilized fairly equally (100-200 surgeons). The number of examinations performed by surgeons before they felt competent was between 11 and 20 and did not vary by the type of ultrasound examination. Of the 267 surgeons performing ultrasound in one clinical area, 176 performed ultrasound-guided procedures. Most surgeons had access to 2 ultrasound machines, but 386 (67%) were restricted from performing ultrasound in certain locations. CONCLUSIONS: The ACoS ultrasound courses are extremely popular and have contributed to the increasing use of ultrasound in surgical practice. Surgeons successfully use ultrasound in their practices including performance of ultrasound-guided procedures but are restricted from using ultrasound in certain patient care areas. Since many surgeons received prior and/or additional training outside of the ACoS, there is a need to facilitate export of ACoS courses to other venues and to focus on incorporating ultrasound training into surgical residency programs.

Capsule endoscopy in 2005: Facts and perspectives.
Delvaux M, Gerard Gay
Best Pract Res Clin Gastroenterol. 2006 Feb;20(1):23-39.

Capsule endoscopy has recently been introduced to explore endoscopically the whole small intestine, fulfilling a gap between examinations of the upper and lower gastrointestinal tract. The technique consists of a miniaturized endoscope, embedded in a swallowable capsule that is propulsed by peristalsis and achieves the journey to the right colon in five to eight hours. Images captured by the capsule are recorded on a hard drive worn in a belt by the patient. The main indication for capsule examination is the examination of the small bowel to find a bleeding lesion in patients with obscure bleeding. Several studies have shown that the diagnostic yield of capsule endoscopy is superior to that of push enteroscopy in this indication. Other possible indications are patients with suspected intestinal location of Crohn's disease, familial adenomatous polyposis, complicated coeliac disease and lesions due NSAIDs. The review contains information on the technical aspects of capsule endoscopy and discusses the indications. Issues of safety and tolerance are also discussed.

Combined low volume polyethylene glycol solution plus stimulant laxatives versus standard volume polyethylene glycol solution: A prospective, randomized study of colon cleansing before colonoscopy.
Hookey LC, Depew WT, Vanner SJ
Can J Gastroenterol. 2006 Feb;20(2):101-5.

INTRODUCTION: The effectiveness of polyethylene glycol solutions (PEG) for colon cleansing is often limited by the inability of patients to drink adequate portions of the 4 L solution. The aim of the present study was to determine whether a reduced volume of PEG combined with stimulant laxatives would be better tolerated and as or more effective than the standard dose. METHODS: Patients undergoing outpatient colonoscopy were randomly assigned to receive either low-volume PEG plus sennosides (120 mg oral sennosides syrup followed by 2 L PEG) or the standard volume preparation (4 L PEG). The subjects rated the tolerability of the preparations and their symptoms. Colonoscopists were blind to the colonic cleansing preparation and graded the cleansing efficacy using a validated tool (the Ottawa scale). RESULTS: The low-volume PEG plus sennosides preparation was significantly better tolerated than the standard large volume PEG (P<0.001) but was less efficacious (P=0.03). Thirty-eight per cent of patients in the large volume PEG group were unable to finish the preparation, compared with only 6% in the reduced volume group. There were no adverse events reported. CONCLUSIONS: Although the low-volume PEG plus sennosides preparation was better tolerated, it was not as effective as standard large-volume PEG. However, in view of the significant difference in tolerance, further research investigating possible improvements in the reduced-volume regimen seems warranted.

Colonoscopy in the Elderly: Low Risk, Low Yield in Asymptomatic Patients.
Duncan JE, Sweeney WB, Trudel JL, Madoff RD, Mellgren AF
Dis Colon Rectum. 2006 Feb 22;.

PURPOSE: Current colonoscopy guidelines do not address the issue of when to stop performing screening and surveillance colonoscopy in the elderly. We reviewed our experience and results of colonoscopy in patients aged 80 years and older to assess the risks and diagnostic yield in this population. METHODS: We reviewed retrospectively the endoscopic and pathologic reports from consecutive colonoscopies performed on patients aged 80 years and older at a single, high-volume endoscopy center between August 1999 and May 2003. Patient characteristics, indications for examination, findings at colonoscopy, and complications were recorded and analyzed. RESULTS: A total of1,199 colonoscopic examinations were performed on 1,112 patients. Average age was 83.1 (range, 80-100) years. Male:female distribution was 1:1.7. Leading exclusive indications for colonoscopy included: polyp surveillance, 227 (19 percent); altered bowel habits, 168 (14 percent); iron-deficiency anemia, 132 (11 percent); and cancer follow-up, 108 (9 percent). Eighty-six examinations (7 percent) were performed solely for an indication of colorectal cancer screening. Twenty-two percent of patients had more than one indication for colonoscopy. Forty-five malignancies were found (3.7 percent). No cancers were found in the screening group, and two malignancies (0.7 percent) were detected in patients undergoing colonoscopy for polyp surveillance. There were eight (0.6 percent) reported major complications. CONCLUSIONS: Colonoscopy can be performed safely in patients aged 80 years and older. However, the diagnostic yield is low, particularly in patients undergoing routine screening or surveillance examinations. Colonoscopy should for the most part be limited to elderly patients with symptoms or specific clinical findings.

Does a negative screening colonoscopy ever need to be repeated?
Brenner H, Chang-Claude J, Seiler CM, Sturmer T, Hoffmeister M
Gut. 2006 Feb 9;.

BACKGROUND: Screening colonoscopy is thought to be a powerful and cost-effective tool to reduce colorectal cancer (CRC) incidence and mortality. Whether and when colonoscopy with negative findings has to be repeated is not well defined. AIM: To assess long-term risk of clinically manifest CRC among subjects with negative findings at colonoscopy. PATIENTS: 380 cases and 485 controls participating in a population-based case-control study in Germany. METHODS: Detailed history and results of previous colonoscopies were obtained by interview and from medical records. Adjusted relative risks of CRC among subjects with a previous negative colonoscopy compared to subjects without previous colonoscopy were estimated according to time since colonoscopy. RESULTS: Subjects with previous negative colonoscopy had a 74% lower risk of CRC than subjects without previous colonoscopy (adjusted odds ratio, aOR, 0.26, 95% confidence interval, CI, 0.16-0.40). This low risk was seen even if the colonoscopy had been performed up to 20 or more years ago. Particularly low risks were seen for sigma cancer (aOR 0.13, 95% CI 0.04-0.43) and for rectum cancer (aOR 0.19, 95% CI 0.09-0.39), and after a negative screening colonoscopy at ages 55-64 (aOR 0.17, 95% CI 0.08-0.39) and older (aOR 0.21, 95% CI 0.10- 0.41). CONCLUSIONS: Subjects with negative findings at colonoscopy are at very low risk of CRC and might not need to undergo repeat colonoscopy for 20 years or more, if at all. The possibility to extend screening intervals to 20 years or more might reduce complications, and increase feasibility and cost-effectiveness of colonoscopy based screening programs.

Enteric flora in health and disease.
Guarner F
Digestion. 2006;73 Suppl 1:5-12. Epub 2006 Feb 8.

The human gut is the natural habitat for a large and dynamic bacterial community. Recently developed molecular biology tools suggest that a substantial part of these bacterial populations are still to be described. However, the relevance and impact of resident bacteria on host's physiology and pathology is well documented. Major functions of the gut microflora include metabolic activities that result in salvage of energy and absorbable nutrients, protection of the colonized host against invasion by alien microbes, and important trophic effects on intestinal epithelia and on immune structure and function. Gut bacteria play an essential role in the development and homeostasis of the immune system. It is important to underscore that the specialised lymphoid follicles of the gut mucosa are the major sites for induction and regulation of the immune system. On the other hand, there is evidence implicating the gut flora in certain pathological conditions, including multisystem organ failure, colon cancer and inflammatory bowel diseases.

January

Meal-induced recto-sigmoid tone modification: a low-caloric meal accurately separates functional and organic gastrointestinal disease patients.
Di Stefano M, Miceli E, Missanelli A, Mazzocchi S, Corazza G
Gut. 2006 Jan 24;.

BACKGROUND AND AIMS: Diagnosis of irritable bowel syndrome is based on arbitrary criteria due to the lack of an accurate diagnostic test. The aim of this study was to evaluate whether recto-sigmoid tone modification after a meal represents an accurate diagnostic approach. METHODS: In a secondary care setting, 32 constipation-predominant and 24 diarrhoea-predominant IBS patients, 10 functional diarrhoea and 10 functional constipation patients, 29 organic gastrointestinal disease patients and 10 healthy volunteers underwent a rectal barostat test in order to measure fasting and post- prandial recto-sigmoid tone. Recto-sigmoid response was assessed following three meals containing different amounts of calories, 200 Kcal, 400 Kcal and 1000 Kcal. RESULTS: After 200 Kcal, healthy volunteers and patients with organic diseases showed a reduction of recto-sigmoid volume of at least 28% of fasting volume, indicating a meal-induced increase of muscle tone. On the contrary, patients with diarrhoea-predominant IBS showed a dilation of the recto-sigmoid colon, indicative of reduced tone and patients with constipation-predominant IBS showed a mild volume reduction or no modification. Functional diarrhoea and constipation patients showed recto-sigmoid tone modification resembling that of the corresponding IBS subtype. A 400 Kcal meal normalized recto-sigmoid tone in more than half the constipation- predominant IBS patients but none of the diarrhoea- predominant IBS patients. On the contrary, a 1000 Kcal meal normalized tone response in all IBS patients. Sensitivity of the test was 100%, specificity 93%, positive predictive value 96% and negative predictive value 100%. CONCLUSION: A post-prandial reduction of recto- sigmoid tone of at least 28% of fasting value after a low- caloric meal accurately separates organic and functional gastrointestinal disease patients. This parameter may, therefore, be used in the positive diagnosis of IBS.

Barostat Measurement of Rectal Compliance and Capacity.
Fox M, Thumshirn M, Fried M, Schwizer W
Dis Colon Rectum. 2006 Jan 20;.

PURPOSE: Fecal continence requires relaxation of the rectal wall and a reservoir of adequate capacity. Rectal compliance provides an assessment of rectal wall stiffness; however, compliance is also affected by rectal capacity. We developed and validated a barostat measurement of rectal capacity. By accounting for variation in rectal capacity, we aimed to improve the inconsistent relationship between rectal compliance, sensation, and continence reported in the literature. METHOD: Barostat measurements of rectal compliance and capacity were validated in 41 healthy, continent subjects. Slow staircase (0-40 mmHg) and rapid phasic (12-40 mmHg) distentions were performed on two separate days, filling sensations were assessed by visual analog score. A stool substitute retention test of rectal filling sensation and continence was performed. RESULTS: Variance of volume measurements decreased with pressure comparing conditioning vs. index distentions, staircase vs. phasic distentions, and measurements on different days (all P < 0.001). Correction for rectal capacity measured at 40 mmHg reduced the "normal range" of compliance measurements (P < 0.01) but not vice versa. Compared with unadjusted volume measurements, normalized rectal volume (percentage filling relative to rectal capacity) improved the description of rectal sensation visual analog score (P < 0.01). Rectal capacity correlated with filling sensations and the volume retained on retention testing (P < 0.01). CONCLUSION: Barostat measurements of rectal capacity at 40 mmHg are highly reproducible and not affected by distention protocol. The assessment of rectal capacity complements that of rectal compliance. Correction for rectal capacity provides an assessment of rectal wall stiffness independent of rectal geometry and improves the association of barostat volume measurements with rectal sensitivity and continence.

Does fecal occult blood testing really reduce mortality? A reanalysis of systematic review data.
Moayyedi P, Achkar E
Am J Gastroenterol. 2006 Feb;101(2):380-4.

INTRODUCTION: Colorectal cancer (CRC) is a common cause of cancer mortality. A variety of CRC screening strategies are being adopted in many developed countries. Fecal occult blood testing (FOBT) is one option for screening that has the most evidence for efficacy and is also the cheapest approach. Systematic reviews suggest that FOBT is effective in reducing CRC mortality but the data on overall mortality from any cause has rarely been synthesized. METHODS: Randomized controlled trials identified by a Cochrane review of the efficacy of FOBT were reanalyzed. Trials that reported on biennial FOBT with all cause mortality assessed at similar follow-up periods were analyzed. CRC, non-CRC, and all cause mortality were evaluated using a random effects model. RESULTS: Three trials were analyzed, involving 245,217 subjects with 2,148 CRC deaths after almost 3 million patient-years follow-up. The relative risk (RR) of CRC death in the FOBT arm was 0.87 (95% CI = 0.8-0.95). The RR of non-CRC death in the FOBT group was 1.02 (95% CI = 1.00-1.04, p= 0.015). The increase in non-CRC in the FOBT group balanced the decrease in CRC mortality with no overall impact on mortality (RR of dying in the FOBT arm = 1.002, 95% CI = 0.989-1.015). CONCLUSION: The impact of FOBT in reducing mortality from any cause is uncertain and efficacy of this strategy for CRC screening needs reevaluation.

Fecal occult blood test screening in the United kingdom.
Steele RJ
Am J Gastroenterol. 2006 Feb;101(2):216-8.

Colorectal Cancer Screening with Fecal Occult Blood Testing (FOBT): An International Perspective.
Achkar E, Moayyedi P
Am J Gastroenterol. 2006 Feb;101(2):212.

Colorectal cancer screening: practices and attitudes of gastroenterologists, internists and surgeons.
Hilsden RJ, McGregor E, Murray A, Khoja S, Bryant H
Can J Surg. 2005 Dec;48(6):434-40.

BACKGROUND: The Canadian Task Force on Preventive Health Care has recommended the use of annual or biennial fecal occult blood testing (FOBT) and flexible sigmoidoscopy in the periodic health examination of asymptomatic people over 50 years of age. Therefore, we decided to ascertain the current colorectal cancer (CRC) screening practices and attitudes of surgeons, gastroenterologists and internists. METHODS: In June 2002 (with a final mailing in December 2002), a questionnaire was sent to all gastroenterologists, internists and surgeons in Alberta. It included items on demographic and practice characteristics, CRC screening practices and opinions about CRC screening. RESULTS: Responses were received from 42 gastroenterologists, 83 internists and 68 surgeons. Overall, 141 of 187 respondents (75.4%, 95% confidence interval [CI] 68.6%-81.4%) recommended that average-risk adults undergo CRC screening. Internists were less likely to recommend screening than either gastroenterologists or surgeons (95% CI for the difference 7.2%-32.8%). The most commonly recommended screening test was colonoscopy (70%), followed by FOBT (65%), flexible sigmoidoscopy (47%) and air-contrast barium enema (31%). Colonoscopy was the only test recommended by 7 (22.6%) of 33 gastroenterologists, 9 (16.4%) of 59 surgeons and 3 (6.1%) of 49 internists. Respondents were more likely to list barriers to the use of colonoscopy (mean 5 barriers) for screening than for either FOBT or flexible sigmoidoscopy (mean 2 barriers for both tests). Only 3 respondents indicated that they themselves would not undergo screening. Colonoscopy was the only screening test that 135 (70.0%) of the 193 would themselves undergo. CONCLUSIONS: The majority of Alberta specialists recommend CRC screening for average-risk adults. Colonoscopy was the most commonly recommended test, despite the perception of more barriers to that technique and the 2001 guidelines prepared by the Canadian Task Force for Preventive Health Care, which did not support colonoscopy.

Fecal occult blood testing options.
Lastella VP
Gastroenterology. 2006 Jan;130(1):285; author reply 285.

Reply.
Ebara M
Gastroenterology. 2006 Jan;130(1):282.

The case for direct colonoscopy screening for colorectal cancer.
Bond JH
Am J Gastroenterol. 2006 Feb;101(2):263-5.

Recent large series of direct colonoscopy screening for colorectal cancer increase our understanding of the advantages of this approach, and have indirectly confirmed efficacy. When performed by well-trained, experienced endoscopists, colonoscopy screening is successful and safe. The prevalence of advanced neoplasia is low under the age of 50 yr but increases substantially with each decade of life thereafter at least until the age of 80 yr. Most detected cancers are at an early, curable stage. A substantial number of proximal advanced neoplasia are detected that would be missed by screening flexible sigmoidoscopy. Widespread population-based colonoscopy screening would markedly decrease the incidence and mortality of this major malignancy. Issues of compliance and capacity related to direct colonoscopy have not yet been adequately addressed.

Colonoscopy, tumors, and inflammatory bowel disease - new diagnostic methods.
Kiesslich R, Hoffman A, Neurath MF
Endoscopy. 2006 Jan;38(1):5-10.

Accurate detection of premalignant lesions and early cancers in the colon is essential for curative endoscopic or surgical therapy, since the prognosis for the affected patients is closely related to the size and stage of the neoplastic lesion. Total colonoscopy is the accepted gold standard for screening and surveillance of colorectal cancer. This review summarizes recently published diagnostic developments and key findings in the areas of colonoscopy, colonic tumors, and inflammatory bowel diseases. Relevant findings have been reported for chromo-endoscopy in the diagnosis of colitis-associated neoplasia, as well as flat and depressed adenomas. Real-time Doppler capabilities have now been added to endoscopic optical coherence tomography; the results of large-scale testing of narrow-band imaging endoscopy in the colon are being awaited; and fluorescence imaging has recently been added to the facilities available in video endoscopy. Most importantly, endomicroscopy now for the first time allows single-cell subsurface imaging during ongoing colonoscopy procedures, opening the way to in-vivo molecular and functional imaging.

Diagnostic and therapeutic impact of double-balloon enteroscopy.
Monkemuller K, Weigt J, Treiber G, Kolfenbach S, Kahl S, Rocken C, Ebert M, Fry LC, Malfertheiner P
Endoscopy. 2006 Jan;38(1):67-72.

BACKGROUND AND STUDY AIMS: Double-balloon enteroscopy (DBE) is a new endoscopic method for examining the small intestine. Most reports of DBE have been from Japan, and very few data on this new technique have been reported by centers outside Japan. The aim of the present study was to determine the diagnostic yield of DBE, measure the frequency of management changes made on the basis of the results, and evaluate the clinical outcome for patients undergoing the procedure. PATIENTS AND METHODS: All patients undergoing DBE using a Fujinon enteroscope (length 200 cm, diameter 8 mm) during a 11-month period were studied. All of the patients had previously undergone esophagogastroduodenoscopy and colonoscopy. They underwent small-bowel cleansing on the day before the procedure using a standard colon lavage solution. RESULTS: Seventy DBE procedures were carried out in 53 patients (34 men, 19 women; mean age 60 years, range 24 - 80) by the oral route in 46 cases and the anal route in 24. The indications for the examination were gastrointestinal bleeding (n = 29), suspected Crohn's disease (n = 6), abdominal pain (n = 4), polyp removal or evaluation in polyposis syndromes (n = 6), chronic diarrhea (n = 4), and surveillance or tumor search (n = 4). The mean duration of the procedure was 72 min (range 25 min - 3 h). The mean radiation exposure was 441 dGy/cm (range 70 - 1462), and the mean depth of small-bowel insertion was 150 cm (range 1 - 470 cm). It was possible to evaluate the entire small bowel in four patients (8 %). A new diagnosis was obtained in 26 of the 53 patients (49 %). The findings in the 70 procedures were angiodysplasia (n = 13), ulcerations or erosions (n = 5), jejunitis or ileitis (n = 5), tumors (n = 5), stenosis (n = 4), polyps (n = 5), lymphangiectasias (n = 4), Crohn's disease (n = 4), and normal (n = 17). DBE resulted in a therapeutic intervention (endoscopic, medical or surgical, excluding blood transfusions) in 57 % of the patients (30 of 53). The only complication (1.4 %) observed was one case of intraprocedural postpolypectomy bleeding, which resolved with injection of epinephrine. CONCLUSION: In almost two-thirds of the patients examined, DBE was clinically useful for obtaining a new diagnosis and starting new treatments, changing existing treatments, carrying out surgical intervention, or providing therapeutic endoscopy. DBE is a useful and safe method of obtaining tissue for diagnosis, providing hemostasis, and carrying out polypectomy.

Preliminary comparison of capsule endoscopy and double-balloon enteroscopy in patients with suspected small-bowel bleeding.
Nakamura M, Niwa Y, Ohmiya N, Miyahara R, Ohashi A, Itoh A, Hirooka Y, Goto H
Endoscopy. 2006 Jan;38(1):59-66.

BACKGROUND AND STUDY AIMS: Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) have been introduced as modalities for examining the entire small bowel. The aim of the present study was to assess the clinical effects of CE and DBE to consider the roles of CE and DBE and the indications for the procedures in patients with suspected small-bowel bleeding. PATIENTS AND METHODS: Between June 2004 and January 2005, 32 patients in whom a site of bleeding in the gastrointestinal tract had not been identified were enrolled in the study. Twenty-eight patients were examined with both methods. Bleeding sources were categorized as either A1 lesions (immediate hemostatic procedures required) or A2 lesions (close observation required). CE and DBE were evaluated with regard to whether or not they were capable of accessing the entire small bowel and provided a diagnosis, and the access and diagnostic rates were calculated. RESULTS: On CE, 13 patients were diagnosed with A1 lesions and six with A2 lesions; on DBE, 11 had A1 lesions and one had an A2 lesion. The access rate for the entire small intestine on CE was 90.6 % (29 of 32), significantly higher than with DBE at 62.5 % (10 of 16; P < 0.05). The diagnostic rate on CE was 59.4 % (19 of 32), higher than with DBE at 42.9 % (12 of 28; P = 0.30), but not significantly different. Among patients with A1 lesions who were diagnosed with DBE, histological diagnoses were obtained in six of the 11, and three patients were treated. CONCLUSIONS: In many suspected small-bowel bleeding cases, CE should be selected for the initial diagnosis and DBE for treatment or histopathological diagnosis after detection of the bleeding site on CE.

Ileus secondary to wireless capsule enteroscopy.
Magdeburg R, Riester T, Hummel F, Lohr M, Post S, Sturm J
Int J Colorectal Dis. 2006 Jan 13;:1-4.

Wireless capsule enteroscopy, being a novel, painless investigative technique, is reported to be significantly superior to push enteroscopy in its ability to find bleeding abnormalities in the small intestine. Here we report a case of acute jejunal obstruction following wireless capsule endoscopy. The patient had a 1-month history of gastrointestinal bleeding of unknown source. Further evaluation including gastroscopy and colonoscopy, angiography and computed tomography (angio-CT), and radio-labeled erythrocytes scan failed to reveal a source of bleeding. Therefore, wireless capsule enteroscopy was performed. Before capsule endoscopy, there was no clinical or imaging evidence of strictures or stenosis. At readmission it could be shown that there were two inflamed strictures of the small intestine. The capsule was detected at a stricture of the small intestine detected by abdominal ultrasonography and conventional computed tomography. The patient underwent a medical treatment with steroidal and other anti-inflammatory drugs for a total of 23 days and was discharged without complaints. Acute laparotomy after readmission with jejunal ileus proofed the capsule occluding two highly inflamed jejunal stenosis caused by Crohn disease. The present case demonstrates the potential for complications when wireless capsule enteroscopy is performed in the presence of intestinal strictures. Any history of inflammatory bowel disease, abdominal irradiation, cancer, obstruction, and abdominal surgery must be elicited in detail and may exclude the use of wireless capsule enteroscopy.

Wireless capsule endoscopy versus ileocolonoscopy for the diagnosis of post-operative recurrence of Crohn's disease: a prospective study.
Bourreille A, Jarry M, D'Halluin PN, Ben-Soussan E, Maunoury V, Bulois P, Sacher-Huvelin S, Vahedy K, Lerebours E, Heresbach D, Bretagne JF, Colombel JF, Galmiche JP
Gut. 2006 Jan 9;.

BACKGROUND AND AIMS: Following ileocolonic resection for Crohn's disease (CD), early endoscopic recurrence predicts the recurrence of symptoms. The aim of the study was to compare ileocolonoscopy and wireless capsule endoscopy (WCE) for the detection of post- operative recurrence in CD. METHODS: WCE and ileocolonoscopy were performed within 6 months following surgery in 32 prospectively enrolled patients. Two independent observers interpreted the results of WCE. Recurrence in the neoterminal ileum was defined by a Rutgeerts' score >/=1. When observers at WCE were did not concur, WCE results were considered either as true negative or true positive and sensitivity (Se) and specificity (Sp) were calculated according to both assumptions. RESULTS: Recurrence occurred in 21 patients (68%) and was detected by ileocolonoscopy in 19 patients. Its sensitivity (Se) was 90% and its specificity (Sp) 100%. The Se of WCE was 62% and 76% and the Sp was 100% and 90% respectively depending of assumptions. There was a correlation between the severity of the lesions measured by both methods (p < 0.05). Lesions located outside the scope of conventional endoscopy were detected by WCE in two-thirds of the patients with an excellent inter- observer agreement (kappa > 0.9) for all lesions with the exception of ulceration (kappa = 0.7). CONCLUSIONS: The sensitivity of WCE to detect recurrence is the neoterminal ileum was inferior to that of ileocolonoscopy. On the other hand, WCE detected lesions in the jejunum and the ileum in more than 2/3 of patients. Additional follow-up studies are needed to assess the clinical relevance of such lesions. At the present time, it seems that WCE cannot systematically replace ileocolonoscopy in the regular management of patients after surgery.

Outcome of capsule endoscopy in determining indication and route for push-and-pull enteroscopy.
Gay G, Delvaux M, Fassler I
Endoscopy. 2006 Jan;38(1):49-58.

BACKGROUND AND STUDY AIM: Video capsule endoscopy and push-and-pull enteroscopy (PPE), both allow a complete examination of the small bowel in patients with suspected intestinal disorders. Due to the invasiveness of PPE, indications should probably be selective. The aim of the present prospective study was to evaluate the outcome of an approach whereby capsule endoscopy was used to select patients in whom PPE was indicated. PATIENTS AND METHODS: 164 patients were included (90 men; age 54+/-18 years) with various indications for small-bowel investigation, such as obscure bleeding (n=88), suspected Crohn's (n=14) or celiac (n=12) disease, or known or strongly suspected localized diseases such as neoplasms (n = 18) for biopsy. Four patients with a suspected intestinal stenosis underwent PPE without prior capsule endoscopy. In the remaining 160 patients, who had a capsule endoscopy, PPE was selected if there were lesions requiring biopsy or angiodysplasias to be treated by argon plasma coagulation (APC). Regarding the insertion route, an anal PPE was indicated if the capsule transit time from ingestion to arrival at the lesion was >or= 75 % of the total time from ingestion to arrival at the cecum. After gut cleansing, PPE was performed with general anesthesia, and the small bowel was examined until the lesion was reached or the scope could not be advanced further. If the suspected lesion had not been reached, a second procedure was performed through the alternative route, under the same conditions. RESULTS: The diagnostic yield of capsule endoscopy was 75 %. According to the indications, 47 PPE procedures were performed in 42 patients, including 33 through the oral route, 4 through the anal route and 5 combined ones. Indications were: suspicion of intestinal tumor (n=13), celiac disease with chronic bleeding (n=4), suspicion of Crohn's disease (n=3), treatment of significant arteriovenous malformations (AVMs) (n=10), diffuse enteropathies (n=3), nonsteroidal anti-inflammatory drug (NSAID)-related conditions (n=2), and obscure digestive bleeding (n=3). Lesions detected by capsule endoscopy were reached by PPE in all but two cases. The positive predictive value (PPV) of capsule endoscopy to make a correct indication for PPE was 94.7 % and the negative predictive value (NPV) was 98.3 %. The PPV and NPV of a time index of > 0.75 to start via the anal route were 94.7 % and 96.7 %. No complications were observed and all patients were discharged the day after the procedure. Follow-up at 9 months showed that capsule endoscopy followed by PPE had positively influenced the management of 90.5 % of the patients. CONCLUSIONS: The use of capsule endoscopy as a filter for PPE results in effective management of patients with various intestinal diseases. Capsule endoscopy can also direct the choice of route of PPE; a time index of > 0.75 appears to reliably indicate an anal route so that a double procedure is required in only about 12 % of cases.

Double-balloon enteroscopy: indications, diagnostic yield, and complications in a series of 275 patients with suspected small-bowel disease.
Heine GD, Hadithi M, Groenen MJ, Kuipers EJ, Jacobs MA, Mulder CJ
Endoscopy. 2006 Jan;38(1):42-8.

BACKGROUND AND STUDY AIMS: Until recently, only the proximal small bowel was accessible for diagnostic and therapeutic endoscopy. This paper describes experience in the first 275 patients examined and treated with the new method of double-balloon enteroscopy (DBE), which is expected to make full-length enteroscopy possible. PATIENTS AND METHODS: Between November 2003 and May 2005, double-balloon enteroscopy was conducted in 275 consecutive patients presenting at two tertiary referral hospitals. The characteristics of the patients, indications for the procedures, procedural parameters, and diagnostic yield are described here. All conventional treatment options were available. The tolerability of the procedure was assessed in a small subset of the patients. After the procedure, the patients were monitored in a recovery room for at least 2h. They were discharged afterwards, provided there were no signs of complications or complaints. RESULTS: The main indication for DBE was suspected small-bowel bleeding (n=168), and the lesions responsible for the bleeding were found in 123 patients (73 %) and treated in 61 (55 %). In patients with refractory celiac disease (n=25), DBE revealed a high proportion (six patients, 23 %) of enteropathy-associated T-cell lymphomas that had not been suspected on other tests. Further DBE indications were surveillance and treatment of hereditary polyposis syndromes (n=20); and suspected Crohn's disease, which was diagnosed with DBE in four of 13 patients (30 %). No relevant pathology was found in 24 % of the patients. Panenteroscopy was successfully performed in 26 of 62 patients (42 %) in whom it was attempted, in either one or two sessions. The average duration of the procedures was 90 min (range 30 - 180 min, SD 42), and the average insertion length was 270 cm (range 60 - 600 cm, SD 104). Patients' tolerance of the procedure was excellent. Severe complications were recognized in three cases (1 %), all involving pancreatitis. CONCLUSIONS: This large pilot series shows that DBE is a well-tolerated and safe new endoscopic technique with a high diagnostic yield in selected patients.

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