Policy of screening for colorectal cancer in Saudi Arabia: A prospective analysis

Colorectal cancer (CRC) is one of the most common cancers worldwide. Several policies of CRC screening are available in different countries. The idea of screening is to identify patients at risk by detection of precancerous and small cancers early enough before they become advanced. In Saudi Arabia (SA), there is no countrywide policy for CRC screening despite the increasing incidence of the disease. Screening for CRC is a multidisciplinary approach that requires education programs, substantial financial support, several logistic measures, and predetermined resources before implementing such a program. We performed a prospective and systematic analysis of the of the screening policy of CRC in SA in view of high demand, anticipated development, and implementation of such a policy in the near future. We also attempted to investigate the justification for developing such a policy, as well as the difficulties, barriers, and opportunities that may be faced in its implementation. Further, we highlighted the current view of similar international screening policies. In this analysis, we adopted the framework for health policy analysis that examines four areas which may affect policy development, namely; content, context, process and actors

Unsedated Colonoscopy: Is It Feasible?

Unsedated colonoscopy has been an evolving subject ever since its initial description four decades ago. Failure in unsedated diagnostic cases due to patient pain led to the introduction of sedation. Extension to screening cases, albeit logical, created a sedation-related barrier to colonoscopy screening. In recent years a water method has been developed to combat the pain during unsedated colonoscopy in the US. In randomized controlled trials the water method decreases pain, increases cecal intubation success, and enhances the proportion of patients who complete unsedated colonoscopy. The salvage cleansing of suboptimal bowel preparation by the water method serendipitously may have increased the detection of adenoma in both unsedated and sedated patients. The state-of-the-art lecture concludes that unsedated colonoscopy is feasible. The hypothesis is that recent advances, such as the development of the water method, may contribute to reviving unsedated colonoscopy as a potentially attractive option for colon cancer screening and deserves to be tested

Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy system

Background/Aim: Open access endoscopy (OAE) decreases the waiting time for patients and clinical burden to gastroenterologist; however, the appropriateness of referrals for endoscopy and thus the diagnostic yield of these endoscopies has become an important issue. The aim of this study was to determine the appropriateness of upper gastrointestinal (GI) endoscopy requests in an OAE system. Patients and Methods: A retrospective chart review of all consecutive patients who underwent an upper gastroscopy in the year 2008 was performed and was defined as appropriate or inappropriate according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines. Endoscopic findings were recorded and classified as positive or negative. Referrals were categorized as being from a gastroenterologist, internist, surgeon, primary care physicians or others, and on an inpatient or out-patient basis. Results: A total of 505 consecutive patients were included. The mean age was 45.3 (standard deviation 18.1), 259 (51%) of them were males. 31% of the referrals were thought to be inappropriate. Referrals from primary care physicians were inappropriate in 47% of patients while only 19.5% of gastroenterologists referrals were considered inappropriate. Nearly, 37.8% of the out-patient referrals were inappropriate compared to only 7.8% for inpatients. Abnormal findings were found in 78.5% and 78% of patients referred by gastroenterologists and surgeons respectively while in those referred by primary care physicians it was (49.7%). Inpatients referred for endoscopy had abnormal findings in (81.7%) while in out-patients it was (66.6%). The most common appropriate indications in order of frequency were "upper abdominal distress that persisted despite an appropriate trial of therapy "(78.9%),′′persistent vomiting of unknown cause "(19.2%), upper GI bleeding or unexplained iron deficiency anemia (7.6%). The sensitivity and specificity of the ASGE guidelines in our study population was 70.3% and 35% respectively. Conclusion: A large proportion of patients referred for endoscopy through our open-access endoscopy unit are considered inappropriate, with significant differences among specialties. These results suggest that if proper education of practitioners was implemented, a better utilization would be expected

Findings during screening colonoscopies in a Middle Eastern cohort

Background/Aims: Colorectal cancer is the most common cancer in males and the third most common cancer in females. We aim to determine the polyp and adenoma prevalence in a cohort of patients who underwent opportunistic screening colonoscopies. Patients and Methods: A retrospective cohort study was conducted using an endoscopic reporting database of individuals seen at three tertiary care hospitals (two public hospitals and one private) in Riyadh, Saudi Arabia. Consecutive patients who were 45 years of age and older and underwent opportunistic screening colonoscopies between November 2016 and October 2017 were included. We excluded those with a history of colon cancer or colonic resection for any reason, inflammatory bowel disease, gastrointestinal bleeding, or anemia. Results: Around 1180 patients were included in the study with a mean age of 58.6 years (SD = 7.3), with males representing 53.6% and an overall cecal intubation rate of 92.4%. Masses were found in 1.6% of the study population (50% in the sigmoid or rectosigmoid, 37.5% in the rectum). The polyp detection rate in colonoscopies was 24.8% and the adenoma detection rate was 16.8%. The histology of removed polyps was tubular adenomas in 56.6%, hyperplastic polyps in 32.7%, tubulovillous adenomas in 8.2%, and villous adenomas in 2.5%. The majority of the polyps were in the sigmoid colon (28.3%) and rectum (22.0%), followed by the ascending colon (11.2%) and cecum (10.3%), then the transverse colon and descending colon (9.4% each), and multiple locations in the remainder. Conclusion: The prevalence of polyps and adenomas in this cohort is less than that reported in the Western populations

Cytologic diagnosis of gastric submucosal lesions by endoscopic ultrasound-guided fine-needle aspiration: A single center experience in Saudi Arabia

Background and Aims: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) sampling has become standard practice for the diagnosis of submucosal gastrointestinal (GI) lesions. The aim of this study was to determine the utility of EUS-guided FNA cytology in the diagnosis of deeply seated gastric mass lesions. Materials and Methods: Thirteen patients with deeply seated gastric mass lesions were diagnosed by EUS-FNA. Adequate cytology material was present in all cases. Cell blocks were available in 10 cases. Surgical resections were performed in 8 cases. Immunohistochemical (IHC) studies were done on cell blocks in 9 cases and on 6 resected specimens. Seven cases has proved to be GI stromal tumors (GIST), in four of them, cell blocks were available, and resection for GIST was performed in 5 cases. IHC stains that were performed in cytology, as well as resection specimens, revealed similar results in each patient. Conclusion: EUS-FNA cytology, when combined with a histologic assessment of cell blocks provides accurate and efficient tissue diagnosis of a wide variety of deeply seated gastric mass lesions

Efficacy of spyglass-guided electrohydraulic lithotripsy in difficult bile duct stones

Background/Aims: We aimed to evaluate the efficacy and safety of Spyglass-guided electrohydraulic lithotripsy (EHL) for difficult common bile duct stones (CBD) not amenable to conventional endoscopic therapy. Design: A retrospective study evaluating the efficacy of Spyglass-guided EHL in treating difficult CBD stones, in a single tertiary care center. Patients and Methods: All patients who underwent Spyglass-guided EHL from 2012 to 2013 were compared with a historical cohort who had ECSWL. Results: A total number of 13 patients underwent Spyglass-guided EHL, 8 (61.5%) of them were males. The mean age was 46.5 ± 5.6 years. Bile duct clearance was achieved in 13 (100%) of them. Seventy-six percent required only one Endoscopic Retrograde Cholangiopancreatography (ERCP) to clear the CBD, 7.7% required two ERCPs, and 15.4% required three ERCPs. Adverse effects (cholangitis) occurred in one patient (10%), whereas only 30 patients (64.4%) of the ESWL group had complete CBD stone clearance. Thirty-seven percent required one ERCP to clear the CBD, 35.6% required two ERCPs, and 20% required three ERCPs. Adverse effects happened in seven (15.5%) patients, where five (11%) had cholangitis and two (4.4%) had pancreatitis. Conclusion: Although a retrospective design with a small sample size, we concluded that Spyglass-guided EHL is an effective procedure in treating difficult CBD stones

Predictors of failure of endoscopic retrograde cholangiography in clearing bile duct stone on the initial procedure

Background/Aims: The aim of this study is to predict cases where the clearance of the biliary system from stones at the initial endoscopic retrograde cholangiopancreatography (ERCP) might be of value for better risk-stratifying patients. We attempted to identify factors that are associated with a higher failure rate of clearing the biliary system on the index ERCP. Patients and Methods: This is a retrospective study from January 2008 to January 2015. All patients with bile duct stones confirmed on ERCP were included in this study. Patients who had prior attempts of bile duct stone extraction were excluded. Results: A total of 554 ERCPs were performed to extract biliary duct stones from 426 patients. The mean age was 46.3 years and 41.7% were males. The group where the index ERCP did not clear the biliary system tended to be older (50.4 vs. 45.2 years, P = 0.03). On multivariate analysis, the presence of fever (OR 4.64; 95% CI, 1.66–12.79), a larger number of filling defects (OR 1.34; 95% CI, 1.13–1.93), presence of a stricture distal to a stone (OR 4.63; 95% CI, 1.36–15.78), the use of an extraction basket (OR 3.23; 95% CI, 1.56–6.74), and/or mechanical lithotripsy (OR 3.05; 95% CI, 1.10–8.49) were all associated with a lower odds of clearing the biliary system. The use of an extraction balloon was associated with the success of clearing the biliary system (99.7% vs. 77.4%, P < 0.01) and a lower odds of failing (OR 0.01; 95% CI, 0.00–0.08) on multivariate analysis. Conclusion: A few of the characteristics that are found on cholangiography at the index ERCP could be used to identify patients that might require more than one ERCP to clear the biliary system from stones