Dilemma of Incomplete Colonoscopy

Transcription

Jonathan A. Leighton, MD, FACG, FASGE
The Dilemma of Incomplete Colonoscopy
What Next?
Mayo Clinic in Arizona
[email protected]
©2013 MFMER | 3316566-1
Why Is Complete Colonoscopy Important?
• Multicenter trial of 1,994 patients undergoing screening
colonoscopy found 50% with significant lesions in proximal colon
• 2012 study found that the risk of proximal cancer increased
twofold when colonoscopy was incomplete
• Guidelines propose targets for successful intubation rates
• ≥90% for all colonoscopies
• ≥95% for screening colonoscopies
p
py can range
g from 7%
% to 19%
%
• Rates of incomplete
colonoscopy
• PopulationPopulation-based study in Canada of 20,166 patients with
incomplete colonoscopy
• Only 29.4% underwent complete exam one year later
Imperiale TF et al: NEJM 2000;343:1692000;343:169-74; Brenner H et al: Ann Intern Med. 2012;157(4):225
2012;157(4):225--232
Rex DK et al: Am J Gastroenterol.
Gastroenterol. 2006;101(4):
2006;101(4):873
873--885; Rizek R. Med Care 2009;47
©2013 MFMER | 3316566-2
ACG Board of Governors/ASGE Best Practices Course - Las Vegas, NV
Copyright 2014 American College of Gastroenterology
1
Completing Colonic Evaluation Is Important
• In a review of 25,451 colonoscopies, Ridolfi et al found
that 242 were incomplete
• 179 (74%) patients underwent a followfollow-up examination
• Overall, followfollow-up examinations indicated clinically
significant lesions in 21 patients (12
(12%)
%)
Follow--up examination
Follow
Patients (n=179*)
Yield
Barium enema
74/179
CT colonography
17/179
New abnormalities
in 11 patients
Repeat colonoscopy
71/179
Colonoscopy with
anesthesia
9/179
27 lesions in
19 patients
CT = computed tomography; Ridolfi E et al: Dis Col Rectum. 2013;56(4):e106
*Remaining 8 patients underwent resection with intraoperative colonoscopy
©2013 MFMER | 3316566-3
Reasons for Incomplete Colonoscopy
Patient Factors
• Discomfort and intolerance
• Low body mass index
• Prior abdomino
abdomino--pelvic surgery
• Suboptimal prep
• Female sex
Technical Factors
• Tortuosity and redundancy
• Angulated and fixed colon segments
• Extensive diverticulosis
Endoscopist and Technician Expertise
1. Rex DK et al: Am J Gastroenterol 2006;101(4):
2006;101(4):873
873--885
2. Rex DK et al: Clin Gastroenterol Hepatol 2007;5(7):879
2007;5(7):879--883
©2013 MFMER | 3316566-4
2
Approach to Difficult Colonoscopy
• Customize the bowel prep and educate
Ch
i t sedation
d ti
• Choose
appropriate
• Ensure expert endoscopist technique
• Train your technicians in abdominal pressure
• Consider the following
• Water exchange
• Magnetic imaging
Anderson ML et al: Gastrointest Endosc 1992;38(5):560
1992;38(5):560--563; Marshall JB et al: Gastrointest Endosc 1993;3(4)9:
518
518--520; Cardin F et al BMC Gastroenterol 2010;10:123; Bourke MJ and Rex DK Am J Gastro 2012;107:14672012;107:1467-72;
Kaminski MF et al: NEJM 2010;362:1795
2010;362:1795--803
©2013 MFMER | 3316566-5
Water Exchange Technique
©2013 MFMER | 3316566-6
3
Without Air Suction
Air Suction from the
Recto-Sigmoid Colon
Recto-
Air suction
Residual air produces an
acute angle in the sigmoid
colon making identification of
the lumen difficult
Water flows out easily and
the sigmoid colon becomes
“SHORT and STRAIGHT”
Mizukami T et al: Dig Endosc 2007;19:432007;19:43-48
©2013 MFMER | 3316566-7
Water Exchange for Redundant Colons
• Benefit during insertion phase of colonoscopy in patients
who are unsedated or receiving minimal sedation
• In a redundant colon, water immersion will keep a dilated colon
collapsed and straighter
B
k MJ and
dR
t 2012
107 1467-72
Bourke
Rex DK
DK: A
Am J G
Gastro
2012;107:1467
2012;107:1467-
Water Exchange in Difficult Colonoscopy
• Water and air methods compared in 44 unsedated patients
with prior abdominal surgery
• Water method: 19/22 (86%)
• Air method: 11/22 (50%)
Leung FW et al: J Interv Gastro 2011; 1:1721:172-76
Water Exchange for Incomplete Colonoscopy
• 10 patients with prior failed cecal intubation referred
for balloon colonoscopy
• All 10 patients underwent successful water exchange
colonoscopy to the cecum
Mann SK et al: Abstract
©2013 MFMER | 3316566-8
4
Magnetic Imaging for Difficult Colonoscopy
©2013 MFMER | 3316566-9
Magnetic coil signals are picked up by small receiver dish
and turned into a dynamic 3D image of the endoscope
©2013 MFMER | 3316566-10
5
©2013 MFMER | 3316566-11
A hand coil enables precise placement for
abdominal pressure in relation to the endoscope
©2013 MFMER | 3316566-12
6
Hand Coil for Loop Reduction
©2013 MFMER | 3316566-13
Magnetic Imaging
• Identify and mitigate loops
A l abdominal
bd i l pressure tto correctt llocation
ti
• Apply
• Recognize difficult anatomy
• Educating fellows on loop reduction techniques
©2013 MFMER | 3316566-15
7
Magnetic Imaging Colonoscopy
296 patients
• No difference in sedation or p
pain scores
• Intubation times were shorter
• Colonoscopy completion rates were higher
• Abdominal hand pressure was more effective
Unsedated colonoscopy comparing magnetic imaging to
standard colonoscopy
• Cecal intubation rate higher in imager group
• 190/212 (90%) vs 153/207 (74%) (P<0.001
(P<0.001))
• Pain
Pain--reducing effect in imager group noted with
experienced colonoscopists:
colonoscopists: 7.3
7.3%
% vs 16% (P=0.03)
Shah SG et al: Lancet 2000;
2000; 356:1718
356:1718--1722
Hoff G et al: Scand J of Gastro 2007;
2007; 42:88542:885-889
©2013 MFMER | 3316566-16
Tips for Difficult Colonoscopy
• Anticipate altered sigmoid anatomy
M t the
th lleft
ft colon
l
• Master
• Change solutions quickly
• Change instruments in the difficult sigmoid
• Be willing to quit
Bourke MJ and Rex DK: Am J Gastro 2012;107:14672012;107:1467-72
©2013 MFMER | 3316566-17
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The Dilemma of Incomplete Colonoscopy
What Next?
Current options
• Double contrast barium enema
• Repeat colonoscopy with or without anesthesia
or with different scope
• CT colonography
• Balloon assisted colonoscopy
Future
technologies
F t
t h l i
• Colon capsule
• CheckCap
Patient factors
Institutional expertise
Available technologies
Hartmann D et al: Endoscopy 39:104139:1041-1045, 2007
Cave D et al: GI Endoscopy 68:48768:487-494, 2008
©2013 MFMER | 3316566-18
Double Contrast Barium Enema
• Adequate colon visualization in 7777-94% after
incomplete colonoscopy
• Main limitation – low sensitivity
• All polyps
40%
40%
• Polyps >1cm 50
50%
%
• CRC miss rate 22
22%
%
• A direct comparison of barium enema with repeat
colonoscopy
for
l
f completion
l ti off colonoscopy
l
ffound
d
that the polyp detection rate was significantly greater
with colonoscopy compared with barium enema
(34.3% vs 3.6%, P <0.0001)
<0.0001)
Chong A et al: Radiology 2002;223:6202002;223:620-4; Martinex F et al: Dis Colon Rectum 2005
2005;; 48:195148:1951-4
Winawer SJ et al: NEJM 2000;342:17662000;342:1766-72; Toma J et al: Am J Gastro 2008
Gawron AJ et al: DDS 2013
2013;; 58:184958:1849-1855
©2013 MFMER | 3316566-19
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Repeat Colonoscopy
• Routine colonoscopy in patients with prior
incomplete
exam,, and repeat
was successful
p
p
in 117 of 119 patients
• Additional methods – applying abdominal pressure,
manual reduction of abdominal wall hernia,
changing the patient’s position, and propofol
sedation
• 59 off 119 patients
have a ttotal
ti t were ffound
d tto h
t l off
126 adenomas <10 mm and 31 adenomas >10 mm
• Haq et al used push enteroscopy in obese or
overweight patients with an 89% success rate
Rex DK et al: Clin Gastroenterol Hepatol 2007
2007;; 5(7):879
5(7):879--883
Haq T et al: Gastrointest Endosc 2010
2010;; 71(5):AB343
71(5):AB343
©2013 MFMER | 3316566-20
CT Colonography (CTC)
• Colonic imaging with multidetector scanners
R
i
b
ti and
d stool
t l ttagging,
i
• Requires
bowell preparation
along with insufflation of the colon with CO²
• Colonic images are obtained using dual position
scanning and analyzed using twotwo-dimensional
axial, multiplanar and three
three--dimensional
endoluminal formats
©2013 MFMER | 3316566-21
10
CT Colonography
©2013 MFMER | 3316566-22
CT Colonography
Colorectal Cancer
C
l
Colonoscopy
3D
2D
©2013 MFMER | 3316566-23
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CT Colonography After
Incomplete Colonoscopy
546 patients after incomplete colonoscopy due to
redundancy or tortuosity
• CTC detected an additional 88 polyps >6mm in size in
13.2% (72) of patients
• Repeat colonoscopy was completed in 63%
• CTC for mass lesions
• Per
Per--patient PPV 90.9%
90.9%
• Per
Per--llesion
91.7%
%
P
i PPV 91.7
91 7
7%
• CTC for large polyps
• Per
Per--patient PPV 64.7%
64.7%
• Per
Per--lesion PPV 70.0%
Copel L et al: Radiology 2007; 244:471244:471-8
©2013 MFMER | 3316566-24
CT Colonography After
• 65 patients with positive FOBT
• CTC performed in 42
• Results
• 21/42 (50%) had polyps or mass lesions
• 15 underwent repeat colonoscopy
• 2 underwent surgery
• CTC
• Per
Per--patient PPV polyps/masses >9mm
>9mm:: 87.5%
87.5%
• Per
Per--lesion PPV polyps/masses: 83.3%
Sali L et al: World J Gastro 2008;
2008; 14:449914:4499-4504
©2013 MFMER | 3316566-25
12
CT Colonography
Advantages
Non--invasive
• Non
• Usually can perform on the same day
• Performed safely in antianti-coagulated patients
Disadvantages
• Radiation
• Low sensitivity
• Air insufflation
• Purely diagnostic
• Extra
Extra--colonic findings
©2013 MFMER | 3316566-26
Balloon Assisted Colonoscopy
• Adjunctive technology that allows for diagnostic
and therapeutic intervention
• Choices
• Double balloon enteroscope
• Single balloon enteroscope
• Double balloon colonoscope
©2013 MFMER | 3316566-27
13
Double Balloon Colonoscopy
©2013 MFMER | 3316566-28
Double Balloon Enteroscopy for
Study
N
Cecal
intubation rate
(%)
Yamamoto 2005
50
98
?
?
Kaltenbach 2006
20
95
28
28±
±20
moderate
Pasha 2007
16
88
27
27±
±9.5
moderate
7
100
15
?
y 2007
Gay
29
96
12
12±
±7
p
p
propofol
Moreels 2008
26
89
20
20±
±2
moderate
Moreels 2010
45
93
19
19±
±1
moderate
Monkemuller 2007
Cecal
intubation time
(min)
Sedation
Yamamoto H et al: Endoscopy 2005;
2005; 37:A53; Kaltenbach T et al: Dig and Liver Dis 2006;38:9212006;38:921-5
Pasha SF et al: GIE 2007; 65; Monkemuller K et al: Scand J Gastro 2007; 42; Gay G et al: Endoscopy 2007; 39:788
Moreels TG et al: CGH 2008; 6:259; Moreels T et al: J Gastro&Hep 2010; 25
©2013 MFMER | 3316566-29
14
Single Balloon Colonoscopy for
Study
N
Cecal
intubation rate
(%)
Total
procecure time
(min)
May 2006
14
100
50
Sedation
Propofol
Teshima 2010
23
96
30
Moderate
Keswani 2011
30
93
22±18 (CI)
Moderate
Coppola 2011
79
94
12 (CI)
Moderate
CI = cecal intubation
May A et al: Enteroscopy 2006; 38:395
38:395--8; Teshima CW et al: GIE 2010
2010;; 7:1319
7:1319--23
Keswani RN: GIE 2011;
2011; 73(3
73(3):
):507
507--512; Coppola F: et al. Dig Liver Dis 2011;
2011; 43(6):
43(6):475
475--477
©2013 MFMER | 3316566-30
Single vs Double Balloon Enteroscopy for
• 53 patients
f l iin cecall intubation
i t b ti iin 26/26
• SBC was successful
• DBC was successful in 25/27 (93%)
• No difference in cecal intubation times
• New polyp detection in both groups
Dzeletovic I et al: DDS 2012:57:26802012:57:2680-2686
©2013 MFMER | 3316566-31
15
Double Balloon Colonoscope for
• Working length – 152 cm; Overtube – 105 cm
• Overcomes
limitations of enteroscope
O
p
• 29 patients
• Cecal intubation rate of 98%
• Shorter total procedure time
• 18 min ± 14 vs 46 min ± 16
• Majority of patients utilized moderate sedation
70%
% due to looping
• 20 patients with incomplete colonoscopy – 70
• With DBC, 95% of procedures were completed
beyond the splenic flexure
• Cecal intubation rate was 80%;
80%; 4 cases were incomplete
due to looping in 3 and angulation in 1
Gay G et al: Endoscopy 2007;39
Ruff K et al: GIE 2009:A69
©2013 MFMER | 3316566-32
Colon Capsule
• Approved in Europe
C
th ends
d
• Cameras
on b
both
• Takes images at a rate of 4 fps
• Measures 31x11mm
• Battery life is 99-10 hours
• Hibernates
Hib
t while
hil capsule
l
passes through small bowel
©2013 MFMER | 3316566-33
16
Colon Capsule Videos
©2013 MFMER | 3316566-34
Colon Polyps
Cecum – Single Polyp
©2013 MFMER | 3316566-35
17
Colon Capsule for Incomplete Colonoscopy
Prospective study of 34 patients with incomplete
colonoscopy underwent colon capsule
• Bowel cleanliness good or excellent in 64.7%
• Capsule exceeded the most proximal point reached by
colonoscoy in 29 patients (85.3%)
• Findings allowed formulation of a specific medical plan
in 20 patients (58.8
(58.8%)
%)
• 12 had no significant lesions
• 7 underwent polypectomy or surgery for
advanced colorectal neoplasia
• 1 was treated for Crohn’s disease
• Inconclusive studies were found in 14
Alarcon--Fernandez O et al: CGH 2013;11:534
Alarcon
2013;11:534--540
©2013 MFMER | 3316566-36
Check--Cap
Check
• Prep
Prep--Free Imaging
S
lik ttechnology
h l
ffor 3
t ti
• Sonar
Sonar-like
3--D reconstruction
of the colon
• Patient ingests a contrast agent that allows
differentiation of stool from colon wall
• Capsule is sensitive to motion and
does
nott scan when
d
h stationary
t ti
• When capsule moves, it emits low
low--dose radiation
Chatrath H and Rex DK. J Clin Gastro 2013
©2013 MFMER | 3316566-37
18
Check--Cap
Check
Capsule in Standby Mode
Capsule in Scan Mode
©2013 MFMER | 3316566-38
Approach to Difficult Colonoscopy
Difficult Colonoscopy
py
Customize
Prep
Magnetic
Imaging
Appropriate
Sedation
Water
Exchange
Expert
Technique
©2013 MFMER | 3316566-39
19
Approach to Incomplete Colonoscopy
Incomplete
Colonoscopy
p
py
Low Risk
Polyps
High Risk
Polyps
CT
Colonography
Repeat
Colonoscopy
Balloon Assisted
Colonoscopy
Future Techonologies
Colon Capsule
CheckCap
©2013 MFMER | 3316566-40
Conclusions
• 7%
7%–
–19%
19% of all colonoscopies are incomplete, although clinical guidelines
recommend that ≥90% of all colonoscopies should be complete
I addition
dditi to
t inadequate
i d
t bowel
b
l preparation,
ti
i
l t colonoscopies
l
i
• In
incomplete
occur most often as a result of technical problems such as looping scope,
patient discomfort, adhesions and obstruction
• The risk of colorectal cancer is increased twofold when
colonoscopy is incomplete
• For difficult colonoscopy, focus on prep, sedation, and expert techniques,
including water immersion and magnetic imaging
• For a history of incomplete colonoscopy but a high risk of polyps
polyps, consider
repeat colonoscopy with adjustments vs balloon
balloon--assisted colonoscopy
• For those patients with a low risk of polyps, one can consider
CT Colonography
• Future modalities include the Colon Capsule and CheckCap
©2013 MFMER | 3316566-41
20

Dilemma of Incomplete Colonoscopy

Transcription

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