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PubMedDate not supplied

A prospective evaluation of successful terminal ileum intubation during routine colonoscopy.

This study prospectively evaluated a dedicated effort to intubate the terminal ileum in an unselected population of patients undergoing colonoscopy in conjunction with our training program. The influence of the visual appearance of the terminal ileal mucosa on patient management was assessed subjectively. The cecum was reached in 270/295 (91%) patients, with successful terminal ileal intubation being accomplished in 213/270 (79%) examinations. The time required to intubate the terminal ileum (x = 3.4 minutes; range, 30 seconds to 10 minutes) was not significantly different (p < 0.05) between the several levels of training in our fellowship program. The terminal ileum was considered to be visually abnormal in 4 cases, but only 1 of these was abnormal on histologic examination. In this unselected population, routine ileoscopy was unrewarding for finding an incidental positive diagnosis; however, brief attempts at terminal ileal intubation may be useful to improve or maintain endoscopic skills, especially in a training setting.

Adult↗
PubMed1996

Detection of dysplasia at colonoscopy using laser-induced fluorescence: a blinded study.

BACKGROUND: Laser-induced fluorescence spectroscopy has the potential to detect colonic dysplasia in vivo. However, previous studies have limited their analyses to multivariate regression techniques and unblinded retrospective evaluation. The purpose of this study was to develop a probability-based algorithm to detect colonic dysplasia using laser-induced fluorescence spectroscopy and to evaluate it in a blinded manner. METHODS: Fluorescence spectra were collected from normal mucosa and colonic polyps during colonoscopy using 370 nm excitation. Tissue was classified as normal, hyperplastic, or adenomatous by histologic examination. Preliminary data was used to devise an algorithm to differentiate tissue type based on probability distributions of the fluorescence intensity at 460 nm and the ratio of the intensity at 680 nm to that at 600 nm. The algorithm was then tested in a blinded fashion. RESULTS: The algorithm correctly determined the tissue type in 88% of cases, equal to the agreement of independent pathologists. Sensitivity, specificity, and positive predictive value for the detection of dysplasia was 90%, 95%, and 90%, respectively. CONCLUSIONS: Dysplasia was detected in vivo using fluorescence spectroscopy and a probability-based algorithm. This method may form the basis for a new surveillance technique for patients with increased risk for dysplastic transformation.

Adenomatous Polyps↗
PubMed1998

Controlled study of cisapride-assisted lavage preparatory to colonoscopy.

BACKGROUND: Traditional bowel preparation before colonoscopy involves lavage with approximately 4 L of polyethylene-glycol (PEG)-electrolyte solution. Using prokinetic agents in addition to PEG-electrolyte lavage may decrease the volume required and ease patient preparation. METHODS: We conducted a blinded, placebo-controlled trial with the prokinetic agent, cisapride, in addition to standard PEG-electrolyte lavage. Patients were prospectively assigned to receive 20 mg of cisapride (n = 52) or placebo (n = 49) 30 minutes before drinking PEG-electrolyte solution. The volume consumed, time to clean bowel, side effects, and acceptance were recorded. Adequacy of colon cleaning was scored by a gastroenterologist blinded to group assignment. RESULTS: Thirty-seven percent of patients assigned to cisapride required more than 3500 mL of PEG-electrolyte, compared with 75% of patients receiving placebo (p < 0.001). Median time to clean bowel was 95 minutes for the cisapride group and 120 minutes for those receiving placebo (p = 0.23). Side effects, patient acceptance, and quality of bowel preparation were not significantly different. CONCLUSION: We conclude that administration of 20 mg of cisapride reduces the required volume of PEG-electrolyte solution for bowel preparation. There were also favorable trends in the time required to achieve clean bowel, patient tolerance, and occurrence of side effects.

Aged↗
PubMed1998

Midazolam versus diazepam in lipid emulsion as conscious sedation for colonoscopy with or without reversal of sedation with flumazenil.

BACKGROUND: The efficacy and tolerance of midazolam (Dormicum R) versus diazepam in lipid emulsion (Diazemuls R, Dumex) was evaluated in a randomized, controlled, double-blind trial in 200 patients undergoing total colonoscopy. METHODS: Diazepam in a dosage of 11.2+/-2.3 mg and midazolam in a dosage of 5.3+/-1.1 mg were given over 2 minutes. Flumazenil in a dosage of 0.2 mg within 15 seconds was administered to 50% of patients after procedure. RESULTS: Diazepam and midazolam were equivalent as judged by sedation, recovery time, patient tolerance, and ease of examination. The effect of flumazenil (Anexate R, Roche) on the recovery time was not significant as most patients were fully awake by the end of the procedure. Midazolam induced significantly more amnesia, and the score for recall of the pain score was significantly less after 14 days in the midazolam group. There were only minor complications in both groups. CONCLUSIONS: We conclude that midazolam can be used safely in relatively fit patients between 17 and 65 years old and that it is the drug of choice if amnesia is desirable. As sole premedication this drug was insufficient in 42% of the patients (pain score was greater than 3), especially in young women.

Adolescent↗
PubMed1999

A comparison of midazolam and diazepam for conscious sedation during colonoscopy in a prospective double-blind study.

BACKGROUND: Midazolam and diazepam are commonly used for conscious sedation, but their comparative respiratory depressive effects have not been accurately studied. We used a novel real-time, on-line, computerized data acquisition system to compare the two agents in a randomized double-blind study. METHODS: One hundred patients undergoing colonoscopy were studied. The maximum end-tidal carbon dioxide tension (PetCO2) and the minimum oxygen saturation by pulse oximetry (SpO 2) were recorded by computer every minute. Patients received meperidine (25 to 50 mg) and incremental doses of either midazolam or diazepam to an identical end point of slurred speech and/or ptosis. Sedation was scored from 1 (unarousable) to 5 (wide awake). RESULTS: Sedation scores were 3.6 +/- 0.1 (mean +/- standard error) after each agent. The doses of midazolam and diazepam were 0. 031 +/- 0.002 and 0.106 +/- 0.009 mg/kg, respectively. In the first 45 minutes (PetCO2) was significantly higher with midazolam than with diazepam (p < 0.05). SpO2 was significantly depressed for 80 minutes after each agent, and the number of minutes when the minimum Sp O2 was less than 90% did not differ between the two agents. CONCLUSIONS: Midazolam was 3.4 times more potent than diazepam. The duration of oxygen desaturation emphasizes the importance of monitoring SpO2 until ventilation and oxygenation have recovered. Although the degree of hypoxemia was comparable, midazolam led to higher end-tidal carbon dioxide tensions.

Adult↗
PubMed1991

Safety, efficacy, and tolerance of intestinal lavage in pediatric patients undergoing diagnostic colonoscopy.

In an open-label prospective study the safety, efficacy, and patient tolerance of an enterally administered isotonic intestinal lavage solution containing polyethylene glycol-3350 was evaluated in 20 pediatric patients (ages 1 1/2 to 19 years) undergoing diagnostic colonoscopy. After an oral dose of metoclopramide, lavage solution was administered by mouth or nasogastric tube at a rate of 40 ml/kg per hour until stools were clear. Emesis occurred in 4 patients, nausea in 11, and abdominal distension in 5. Clear stools were produced in a mean (+/- SE) time of 2.6 +/- 0.3 hours. The volume of lavage solution delivered, which ranged from 15.6 to 183.3 ml/kg, varied inversely with the weight (and age) of the patient. Preparation of the colon was considered optimal in 11 patients, satisfactory in 7, and suboptimal in 2. Small but significant decreases in urine osmolality, blood urea nitrogen, serum glucose, and potassium values were noted at the termination of perfusion. Postperfusion serum glucose concentration in the smallest patient (11.4 kg) was 61 mg/dL (3.4 mmol/L). Mean (+/- SEM) change in weight after perfusion was 0.14 +/- 0.05 kg (range -0.2 to +0.6 kg). Of 20 patients, 11 required or requested nasogastric administration of the lavage solution because of its unpleasant taste. We conclude that whole intestinal perfusion with a balanced electrolyte solution containing polyethylene glycol is safe, acceptable, and efficacious in children.

Adolescent↗
PubMed2000

Flat and depressed colonic neoplasms: a prospective study of 1000 colonoscopies in the UK.

BACKGROUND: Flat and depressed colorectal tumours were originally thought to be unique to the Japanese population. Recently there have been reports of flat and depressed lesions in western countries but they have been thought to be uncommon. METHODS: In this prospective study, 1000 consecutive patients attending for routine colonoscopy were examined for flat or depressed lesions. The examinations were done by one European colonoscopist using methods developed in Japan. FINDINGS: 321 adenomas were found: 202 (63%) were polypoid, 36% (117) were flat and 2 (0.6%) appeared depressed. Most adenomas contained areas of mild or moderate dysplasia but 10% (31) were severely dysplastic. Six Dukes' A adenocarcinomas were identified together with 25 more advanced adenocarcinomas. The likelihood of Dukes' A cancer or severe dysplasia increased from 4% (3/70) in small flat lesions, to 6% (9/154) in small polyps, 16% (8/50) in larger polyps, 29% (14/49) in large flat lesions, and 75% (3/4) in depressed lesions. 54% (20/37) lesions containing severe dysplasia or Dukes' A carcinoma were flat or depressed. INTERPRETATION: The polyp-carcinoma hypothesis prompts colonoscopists to search only for polypoid lesions when screening for cancer, and many early colorectal neoplasms may therefore be missed. Colonoscopists require training in the recognition of flat and depressed lesions to detect colorectal tumours in the early stages.

Adenocarcinoma↗
PubMed1994

Are we telling patients the truth about surveillance colonoscopy in ulcerative colitis?

The recommended approach to the increased risk of colorectal carcinoma in ulcerative colitis has been colonoscopic surveillance rather than prophylactic colectomy. This strategy is based on the assumption that dysplastic lesions can be detected before invasive cancer has developed. We have analysed published reports on dysplasia surveillance to find out whether this assumption is valid. Ten prospective studies (1225 patients) satisfied our criteria. Of 40 patients with dysplasia-associated mass or lesion (DALM) detected, 17 (43%) already had cancer at immediate colectomy. The risks of cancer at immediate colectomy were 42% (10 of 24 patients) for high-grade and 19% (3 of 16) for low-grade dysplasia. Of 47 patients found to have high-grade dysplasia after the initial colonoscopy, 15 (32%) had cancer. 16-29% of patients with untreated low-grade dysplasia progressed to DALM, high-grade dysplasia, or cancer. Of patients with indefinite results, 28% progressed to high-grade dysplasia and 9% to cancer, so continued surveillance is essential. The risk of progression to dysplasia was only 2.4% for patients whose initial result was negative, so surveillance could perhaps be less frequent for these patients. Immediate colectomy is essential for all patients diagnosed with high-grade or low-grade dysplasia. A diagnosis of dysplasia does not preclude the presence of invasive cancer. We believe that patients should be informed about the limitations of colonoscopic surveillance so that they can take part rationally in decision-making about their management.

Colitis, Ulcerative↗
PubMed2001

Colonoscopy, proctoscopy, and ileoscopy.

Colonoscopy and proctoscopy are primarily performed on dogs and cats with signs of chronic large bowel or rectal disease, and ileoscopy is typically performed in patients with signs of either large or small bowel disease. These techniques should not be used indiscriminately but only on animals that have a reasonable chance to benefit from their use. Even then, the techniques must be performed carefully so that the results are meaningful instead of misleading. We first consider what does and what does not constitute a reasonable indication for endoscopic examination of the lower intestines. After that, we turn to the specific techniques involved.

Animals↗
PubMed1993

[Tetraplegia after colonoscopy: benzodiazepine withdrawal syndrome induced by flumazenil?].

A case is reported of a 68-year-old female patient who developed a flaccid tetraplegia on recovering from a colonoscopy, carried out under general anaesthesia (3 mg of midazolam, 20 mg of etomidate). During the preanaesthetic visit, she omitted to report a 15-year-addiction to lorazepam 2.5 mg every night. At the end of the procedure, 0.2 mg of flumazenil were injected. Recovery was immediate but followed by neurological signs associating general weakness, paraesthesia and tetraplegia. These symptoms discontinued spontaneously two hours later. She was discharged the same day but complained of myalgia and paraesthesia for a week. The physiopathology of this accident is unknown. The differential diagnosis and the influence of flumazenil on benzodiazepine withdrawal are discussed.

Aged↗
PubMed1999

Virtual colonoscopy.

Virtual colonoscopy (VC) is an evolving technique that combines volume scanning and computer visualization methods to enable minimally invasive and effective colorectal cancer screening. Although VC offers significant clinical and public health advantages over conventional endoscopic screening, several issues confront VC's emergence into the medical marketplace.

Colonoscopy↗
PubMed2002

Colonoscopy and polypectomy.

Colonoscopy and polypectomy, when performed by adequately trained physicians, is a safe and effective procedure that can decrease deaths resulting from colorectal cancer.

Colonic Neoplasms↗
PubMedDate not supplied

Automatic segmentation of the colon for virtual colonoscopy.

Virtual colonoscopy is a minimally invasive technique that enables early detection of colorectal polyps and cancer. Normally, a patient's bowel is prepared with colonic lavage and gas insufflation prior to computed tomography scanning. An important step for 3D analysis of the image volume is segmentation of the colon. The high-contrast gas/tissue interface that exists in the colon lumen makes segmentation of the majority of the colon relatively easy; however, two factors inhibit automatic segmentation of the entire colon. First, the colon is not the only gas-filled organ in the data volume: lungs, small bowel, and stomach also meet this criterion. User-defined seed points placed in the colon lumen have previously been required to spatially isolate the colon. Second, portions of the colon lumen may be obstructed by peristalsis, large masses, and/or residual feces. These complicating factors require increased user interaction during the segmentation process to isolate additional colonic segments. To automate the segmentation of the colon, we have developed a method to locate seed points and segment the gas-filled lumen sections without user supervision. We have also developed an automated approach to improve lumen segmentation by digitally removing residual contrast-enhanced fluid. Experimental results with 20 patient volumes show that our method is accurate and reliable.

Algorithms↗
PubMed2006

Surveillance colonoscopy in patients with colorectal cancer: how often should we be doing it?

BACKGROUND: The optimum protocol for colonoscopic surveillance following curative resection for colorectal cancer has not been established. The aim was to assess the incidence of recurrence and metachronous tumours in our less intensive colonoscopic surveillance programme and compare our results with those reported from intensive surveillance programmes. METHODS: Colonoscopic records of patients who had surveillance colonoscopy following curative resection from April 1998 to March 2003 for cancer were available from the endoscopy department computer database. The variables studied included the tumour site, Duke's stage, number of recurrences, number of metachronous tumours, size and number of polyps and their biopsy results. RESULTS: There were a total of 105 patients. Two patients were diagnosed with metachronous tumours and three with recurrence. Adenomatous polyps were identified in 24 patients of which nine had multiple/advanced adenomas (equal to or more than 1cm adenomatous polyps, or with severe dysplasia). CONCLUSION: The risk of development of colonic pathology following curative resection for colorectal cancer is low. More intensive follow-up should be reserved for patients with additional risk of developing further cancers.

Adenoma↗
PubMed2003

Colonoscopy or barium enema for population colorectal cancer screening?

There is good evidence from faecal occult blood testing trials that detection and removal of non-advanced colorectal neoplasms can achieve a reduction in colorectal cancer mortality. Both colonoscopy and barium enema have potential advantages and disadvantages if implemented for population screening. The relative merits of each are discussed.

Barium Sulfate↗
PubMed2001

Cancer prone persons. A randomized screening trial based on colonoscopy: background, design and recruitment.

OBJECTIVE: Evidence-based counseling and prevention are not available so far for hereditary cancer prone persons, since we lack data based on clinical trials. There are very few high-risk persons in the population as a whole. Based on a familial history analysis, only 1.2% of all healthy volunteers attending screening centers reached the arbitrary high-risk level defined as a Relative Risk of more than 4. We describe a randomized trial based on colonoscopic screening for colorectal cancer on a sub-group of high-risk group persons. MATERIALS AND METHODS: Among the 77 members of the French Institutional Preventive Center Network, 37 took part in this protocol. During the first 3 years, 850,000 persons were interviewed at these 37 Health centers. The enrollment process was particularly time-consuming, since a large amount of information had to be delivered to the participants. RESULTS: The mean rate of recruitment of eligible candidates was far lower than predicted, averaging only 1.4 per 1,000 persons interviewed instead of the 9/1,000 expected. This mean figure was based, however, on inclusion rates ranging from 0.06/1,000 to 7/1,000 among the different centers. The low rates of recruitment were mainly due to the inter-center heterogeneity (differences in commitment and in the resources), and to the fact that the acceptability of undergoing a colonoscopy turned out to be lower than predicted. CONCLUSION: Population trials on cancer prone persons are feasible, but vast numbers have to be pre- screened to identify the few people with a high hereditary risk and willing to accept screening within a controlled trial.

Adolescent↗