Diagnostic accuracy of narrow-band imaging and pit pattern analysis significantly improved for less-experienced endoscopists after an expanded training program

Background: Previous reports assessing diagnostic skill using narrow-band imaging (NBI) and pit pattern analysis for colorectal polyps involved only highly experienced endoscopists. Objective: To evaluate diagnostic skills of less-experienced endoscopists (LEE group) for. differentiation of diminutive colorectal polyps by using NBI and pit pattern analysis with and without magnification after an expanded training program. Design: Prospective study. Patients: This study involved 32 patients with 44 colorectal polyps (27 adenomas and 17 hyperplastic polyps) of 5 mm that were identified and analyzed by using conventional colonoscopy as well as non-magnification and magnification NBI and chromoendoscopy followed by endoscopic removal for histopathological analysis. Intervention: Before a training course, 220 endoscopic images were distributed in randomized order to residents with no prior endoscopy experience (NEE group) and to the LEE group, who had performed colonoscopies for more than 5 years but had never used NBI. The 220 images were also distributed to highly experienced endoscopists (HEE group) who had routinely used NBI for more than 5 years. The images were distributed to the NEE and LEE groups again after a training class. Magnification NBI and chromoendoscopy images were assessed by using the Sano and Kudo classification systems, respectively. Main Outcome Measurements: Diagnostic accuracy and interobserver agreement for each endoscopic modality in each group. Results: Diagnostic accuracy was significantly higher, and kappa (kappa) values improved in the LEE group for NBI with high magnification after expanded training. Diagnostic accuracy and kappa values when using high-magnification NBI were highest among endoscopic techniques for the LEE group after such training and the HEE group (accuracy 90% vs 93%; kappa = 0.79 vs 0.85, respectively). Limitations: Study involved only polyps of <= 5 mm. Conclusion: Using high-magnification NBI increased the differential diagnostic skill of the LEE group after expanded training so that it was equivalent to that of the HEE group

Efficacy of capillary pattern type IIIA/IIIB by magnifying narrow band imaging for estimating depth of invasion of early colorectal neoplasms

<p>Abstract</p> <p>Background</p> <p>Capillary patterns (CP) observed by magnifying Narrow Band Imaging (NBI) are useful for differentiating non-adenomatous from adenomatous colorectal polyps. However, there are few studies concerning the effectiveness of magnifying NBI for determining the depth of invasion in early colorectal neoplasms. We aimed to determine whether CP type IIIA/IIIB identified by magnifying NBI is effective for estimating the depth of invasion in early colorectal neoplasms.</p> <p>Methods</p> <p>A series of 127 consecutive patients with 130 colorectal lesions were evaluated from October 2005 to October 2007 at the National Cancer Center Hospital East, Chiba, Japan. Lesions were classified as CP type IIIA or type IIIB according to the NBI CP classification. Lesions were histopathologically evaluated. Inter and intraobserver variabilities were assessed by three colonoscopists experienced in NBI.</p> <p>Results</p> <p>There were 15 adenomas, 66 intramucosal cancers (pM) and 49 submucosal cancers (pSM): 16 pSM superficial (pSM1) and 33 pSM deep cancers (pSM2-3). Among lesions diagnosed as CP IIIA 86 out of 91 (94.5%) were adenomas, pM-ca, or pSM1; among lesions diagnosed as CP IIIB 28 out of 39 (72%) were pSM2-3. Sensitivity, specificity and diagnostic accuracy of the CP type III for differentiating pM-ca or pSM1 (<1000 μm) from pSM2-3 (≥1000 μm) were 84.8%, 88.7 % and 87.7%, respectively. Interobserver variability: κ = 0.68, 0.67, 0.72. Intraobserver agreement: κ = 0.79, 0.76, 0.75</p> <p>Conclusion</p> <p>Identification of CP type IIIA/IIIB by magnifying NBI is useful for estimating the depth of invasion of early colorectal neoplasms.</p

Coronary abnormal response has increased in Japanese patients: Analysis of 17 years’ spasm provocation tests in 2093 cases

SummaryBackgroundAbnormal coronary response on acetylcholine test is observed in patients with early coronary atherosclerosis.ObjectivesWe analyzed retrospectively the abnormal response rate during 17 years of spasm provocation tests in 2093 consecutive patients.MethodsWe performed 2093 spasm provocation tests, consisting of 1198 acetylcholine tests and 895 ergonovine tests, between January 1991 and December 2007. Spasm provocation test was mainly performed in patients with ischemic heart disease. Abnormal response was defined as transient >90% luminal narrowing during spasm provocation tests. We classified these 17 years into two periods: former period from January 1991 to December 2000, and the latter period from January 2001 to December 2007. In the former period, 1300 spasm provocation tests were performed and 793 spasm provocation tests were done in the latter period.ResultsThe incidences of hypertension, dyslipidemia, and diabetes mellitus were significantly increased in the latter period. The values of total cholesterol, triglycerides, and fasting blood sugar were also significantly increased in the latter period. The frequency of abnormal response in the latter period was significantly higher than that in the former period (46.0% vs. 33.2%, p<0.05). The frequency of abnormal coronary response to acetylcholine in the latter period was significantly higher than that in the former period (60.0% vs. 34.0%, p<0.01), whereas there was no difference concerning abnormal response of ergonovine between the two periods (31.9% vs. 30.7%, ns).ConclusionsIn Japanese patients, abnormal coronary response to acetylcholine has increased and coronary endothelial dysfunction is suggested to have progressed

Una nueva disección submucosa endoscópica asistida por plomada para el cáncer colorrectal

10 páginasBackground Endoscopic submucosal dissection (ESD) is accepted as a minimally invasive treatment for early gastric cancer, but it is not widely used to treat the colorectum because of its degree of technical difficulty. Thus, a noninvasive tool that facilitates the direct visualization of the submucosal layer is needed. Methods Traction-assisted dissection was performed on 4 superficial lesions. The system consisted of a metallic clip attached by a nylon line to a sinker 6 × 4 × 4 mm in size and weighing 1 g. After partially dissecting the submucosa, the clip was attached to the edge of the exfoliated mucosa and the weight of the sinker pulled down the partly resected lesion. Observations In all 4 cases, the sinker allowed direct visualization of the cutting line, and en bloc resection was successfully accomplished. Conclusions These preliminary results suggest that sinker-assisted ESD is effective for the complete removal of selected superficial early colorectal cancer.Fondo La disección submucosa endoscópica (DES) se acepta como un tratamiento mínimamente invasivo para el cáncer gástrico temprano, pero no se usa mucho para tratar el colon y recto debido a su grado de dificultad técnica. Por lo tanto, se necesita una herramienta no invasiva que facilite la visualización directa de la capa submucosa. Métodos Se realizó disección asistida por tracción en 4 lesiones superficiales. El sistema consistía en un clip metálico unido por una línea de nailon a una plomada de 6 × 4 × 4 mm de tamaño y 1 g de peso. Después de disecar parcialmente la submucosa, el clip se adhirió al borde de la mucosa exfoliada y el peso de la plomada arrastró hacia abajo la lesión parcialmente resecada. Observaciones En los 4 casos, la plomada permitió la visualización directa de la línea de corte y la resección en bloque se logró con éxito. Conclusiones Estos resultados preliminares sugieren que la ESD asistida por plomada es efectiva para la extirpación completa del cáncer colorrectal superficial temprano seleccionado

Eficacia de la cromoendoscopia de aumento para el diagnóstico diferencial de lesiones colorrectales†

10 páginasMagnifying chromoendoscopy is an exciting new tool and offers detailed analysis of the morphological architecture of mucosal crypt orifices. In this review, we principally show the efficacy of magnifying chromoendoscopy for the differential diagnosis of colorectal lesions such as prediction between non-neoplastic lesions and neoplastic ones, and distinction between endoscopically treatable early invasive cancers and untreatable cancers based on a review of the literature and our experience at two National Cancer Centers in Japan. Overall diagnostic accuracy by conventional view, chromoendoscopy and chromoendoscopy with magnification ranged from 68% to 83%, 82% to 92%, and 80% to 96%, respectively, and diagnostic accuracy of accessing the stage of early colorectal cancer using magnifying colonoscopy was over 85%. Although the reliability depends on the skill in magnifying observation, widespread applications of the magnification technique could influence the indications for biopsy sampling during colonoscopy and the indication for mucosectomy. Moreover, the new detailed images seen with magnifying chromoendoscopy are the beginning of a new period in which new optical developments, such as narrow band imaging system, endocytoscopy system, and laser-scanning confocal microscopy, will allow a unique look at glandular and cellular structures.La cromoendoscopia de aumento es una herramienta nueva y emocionante que ofrece un análisis detallado de la arquitectura morfológica de los orificios de las criptas mucosas. En esta revisión, mostramos principalmente la eficacia de la cromoendoscopia de aumento para el diagnóstico diferencial de las lesiones colorrectales, como la predicción entre lesiones no neoplásicas y neoplásicas, y la distinción entre cánceres invasivos tempranos tratables endoscópicamente y cánceres intratables en base a una revisión de la literatura y nuestra experiencia en dos Centros Nacionales del Cáncer en Japón. La precisión diagnóstica general mediante vista convencional, cromoendoscopia y cromoendoscopia con aumento varió del 68 % al 83 %, del 82 % al 92 % y del 80 % al 96 %, respectivamente, y la precisión diagnóstica de acceso a la etapa de cáncer colorrectal temprano mediante colonoscopia con aumento fue más del 85%. Aunque la fiabilidad depende de la habilidad para ampliar la observación, las aplicaciones generalizadas de la técnica de ampliación podrían influir en las indicaciones para la toma de muestras de biopsia durante la colonoscopia y la indicación de mucosectomía. Además, las nuevas imágenes detalladas vistas con cromoendoscopia de aumento son el comienzo de un nuevo período en el que los nuevos desarrollos ópticos, como el sistema de imagen de banda estrecha, el sistema de endocitoscopia y la microscopia confocal de barrido láser, permitirán una mirada única a las estructuras glandulares y celulares.

Current status and future perspectives of endoscopic diagnosis and treatment of diminutive colorectal polyps

During colonoscopy, small and diminutive colorectal polyps are commonly encountered. It is estimated that at least one adenomatous polyp is detected in almost half of all patients undergoing screening colonoscopy. In contrast, the ‘predict, resect, and discard’ strategy for diminutive and small colorectal polyps is a current topic especially in Western countries. ‘Is this an acceptable policy in Japan?’ Herein, we report the results of a questionnaire survey with regard to the management of diminutive colorectal polyps, including the thoughts of Japanese endoscopists regarding the ‘predict, resect, and discard’ strategy. At the moment, we propose that this strategy should be used by skilled endoscopists only