Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) still plays an important role in the diagnosis and treatment of biliopancreatic disease. Especially for inexperienced endoscopists, transpapillary biliary cannulation is difficult, and thus the success rate of selective bile duct cannulation is low. Understanding the exact morphology and opening of the common bile duct is important for determining the success of bile duct cannulation. Texture and color enhancement imaging (TXI) is an imaging technique that optimizes three mucosal surface elements: structure, brightness, and color tone, and has been reported to enhance slight changes in structure and color tone that are difficult to see with white light imaging (WLI). Therefore, we aimed to investigate whether TXI mode 1 could improve papillary recognition by trainees inexperienced in ERCP.

Aims & Methods

This retrospective single-center study was conducted in Japan and used electronic medical records to extract data regarding participants’ age, sex, and the endoscopic procedure they underwent. We included 31 patients with naive major duodenal papilla in the study. According to the Inomata classification, the papilla of Vater was classified into one of six categories. We classified the papillae into two groups to determine their distinctive qualities: the separate and septal type groups. The trainees were defined as unskilled endoscopists with less than 100 cases and less than 3 years of ERCP experience, while experienced endoscopists were defined as those with more than 1000 cases and more than 10 years of ERCP experience. Trainee endoscopists (n = 4) evaluated and identified the papilla according to the Inomata classification using WLI and TXI. The degree of agreement with the evaluation of supervising physicians (n = 4) was examined using the McNemar test. This study was approved by the Institutional Review Board of Saitama Medical University International Medical Center (2021–203).

Results

The concordance rate between the four trainees was evaluated, and Fleiss’ kappa values were calculated for inter-subject coefficient agreement. The two groups (separate group vs. septal group) of papilla agreements were evaluated, and the result for WLI was low (κ = 0.35), whereas the result for TXI was high (κ = 0.75). In addition, comparison of the response concordance rate for the two-step evaluation between WLI and TXI, one of the four trainees showed a significant increase in concordance from 76.7% to 96.7% (p = 0.03). Furthermore, in the comparison test for the kappa coefficient, two of the four trainees showed a significant increase in concordance, from 0.34 to 0.92 (p = 0.01) and from 0.45 to 0.92 (p = 0.02), respectively.

Conclusion

TXI can selectively emphasize the irregularities of the major duodenal papilla and highlight subtle tissue differences, such as the mouth of the bile duct and the pancreatic duct, and slight changes in morphology and color. Observation of the major duodenal papilla using TXI improved the morphology and opening of the papilla and suggested the potential of TXI as a clinical tool. Although more cases need to be accumulated, TXI may help inexperienced endoscopists perform biliary cannulation.

Disclosure

The authors declare no conflicts of interest for this article.

Introduction

Cancer is the second leading cause of death globally. Colon cancer is the fifth most prevalent type of cancer. Screening, particularly colonoscopy, reduces incidence by 40% and mortality by 50%. The process of bowel preparation before a colonoscopy is complex and requires the patient’s compliance. Enhanced education using a smartphone application has been shown to improve bowel preparation quality. However, heterogeneity was observed among the studies.

Aims & Methods

AIMS: To determine if providing instructions through an application enhances bowel preparation quality in Thai patients undergoing elective colonoscopy.

METHODS: From July 2022 to January 2024, a prospective, endoscopist-blinded, randomized, controlled trial was conducted. Consecutive patients aged > 18 years old who had convenient access to the Line application were randomly assigned in a 1:1 ratio to be educated via the smartphone application (APP group) or the standard education (control group). All patients received the same purgative regimen. The primary outcome was the Boston Bowel Preparation Scales (BBPS). Secondary outcomes included adenoma detection and cecal intubation rates, cecal intubation time, withdrawal time, and patient satisfaction.

Results

The trial aims to recruit 488 patients. A total of 272 patients (APP group, n = 131; control group, n =141) were preliminary analyzed. The mean age was 61.5 years old, and 29% were male. The mean BBPS was comparable between the APP and control groups (8.30 ± 0.99 vs 8.51 ± 1.19, P = 0.173). Both groups achieved adequate bowel preparation (BBPS>6) in 99.2% of cases. All secondary outcomes corresponded with the primary outcome. In the subgroup analysis among the elderly, levels of education, income, and waiting times for colonoscopies, BBPS was not impacted by the providing methods. No adverse events related to education were observed.

Conclusion

Both standard and enhanced education using the smartphone application resulted in excellent bowel preparation. Eligible patients included in this study might influence this outcome. However, using the smartphone application was well-received and could potentially replace standard education for bowel preparation.

References

1. Virani S, Bilheem S, Chansaard W, Chitapanarux I, Daoprasert K, Khuanchana S, et al. National and Subnational Population-Based Incidence of Cancer in Thailand: Assessing Cancers with the Highest Burdens. Cancers. 2017;9(8):108.

2. May FP, Shaukat A. State of the Science on Quality Indicators for Colonoscopy and How to Achieve Them. Official journal of the American College of Gastroenterology | ACG. 2020;115(8):1183-90.

3. Desai M, Nutalapati V, Bansal A, Buckles D, Bonino J, Olyaee M, et al. Use of smartphone applications to improve quality of bowel preparation for colonoscopy: a systematic review and meta-analysis. Endosc Int Open. 2019;7(2):E216-E24.

Introduction

Effective colorectal cancer prevention relies on the quality of screening colonoscopy examinations. Cecal withdrawal time is significantly associated with adenoma detection rate (ADR), which is an established quality indicator for screening colonoscopy. Therefore, we introduced a real-time cecal withdrawal timer (CWT) that alerts the physician of the elapsed time since cecal intubation.

Aims & Methods

An observational, retrospective, single-center study to evaluate CWT in screening colonoscopy tests. The CWT is activated by a vocal command when the physician achieves cecal intubation. Following activation, the elapsed time is audio-announced every minute until the end of the procedure. The ADR of colonoscopies with and without the CWT was evaluated following CWT implementation from January 2023 to February 2024. Moreover, the ADR of the entire department in this period was compared with the year before.

Results

Of 1,557 colonoscopies between January 2023 and February 2024, 908 (58.3%) were performed with the CWT with a median withdrawal time of 8.75 (IQR: 6.9-12.0) minutes. During this period, the CWT usage was greater than 50% in 11 out of 14 months. Considering only months with CWT usage over 50%, the ADR of colonoscopies with CWT was 28.3% compared to 19.2% in those without (p<0.001). Among physicians who performed at least 20 tests with and 20 tests without the CWT, 6 out of 8 demonstrated improved ADR with the cecal timer. Notably, the 2 physicians who did not improve ADR had baseline ADR exceeding 30%. The overall ADR of the department between January 2023 and February 2024 was 25.5%, compared to 26.2% in 2022 (p=0.704).

Conclusion

Initial findings of the CWT program suggest its potential in enhancing screening colonoscopy quality indicators, although long-term prospective follow-up is warranted.

Disclosure

Nothing to declare

Introduction

Inadequate bowel preparation is linked to reduced adenoma detection rates (ADR), and establishing a threshold for bowel preparation below which colonoscopies should be repeated early is crucial for patient outcomes. However, manual bowel cleansing efficacy evaluation relies on the clinical observer's experience, resulting in subjectivity with clinical and economic implications. The Boston Bowel Preparation Scale (BBPS) is the most validated scoring scale. Our group previously constructed an AI-based bowel preparation assessment model to calculate e-BBPS scores.

Aims & Methods

This prospective, single-center study was conducted at the Eighth Affiliated Hospital, Sun Yat-sen University in China from October 2021 to November 2022. Eligible patients underwent screening colonoscopy by one of three study endoscopists. The AI calculated the e-BBPS score during colonoscope withdrawal. The endoscopist assessed bowel preparation adequacy using BBPS after the colonoscopy. If both BBPS and e-BBPS deemed bowel preparation adequate, the same endoscopist performed a second colonoscopy. If either considered it inadequate, the patient underwent bowel re-cleansing before the second colonoscopy. Video recordings were evaluated for bowel preparation using BBPS by five independent endoscopist raters.

Results

From October 8, 2021, to November 9, 2022, a total of 393 patients were included for analysis. In patients with unqualified-AI, the >5mm AMR was significantly higher than in patients with qualified-AI (p=0.0056, OR 0.2734, 95% CI 0.1139, 0.6565), as were the AMR <0.001 (p=0.2532, 95% CI 0.1583, 0.4052), diminutive AMR (p<0.001, OR 0.2160, 95% CI 0.1206, 0.3867), >5mm PMR (p=0.0152, OR 0.4335, 95% CI 0.2288, 0.8213), and PMR (p <0.001, OR 0.4532, 95% CI 0.3447, 0.5958). No significant differences were observed in the overall >5mm ADR, ADR, >5mm PDR, and PDR. In the first pass, no statistical differences were found in ADR between the qualified-AI and unqualified-AI groups, though there was a trend toward a higher ADR in the qualified-AI group. In the second pass, patients in the qualified-AI group achieved significantly lower >5mm ADR, ADR, diminutive ADR, advanced ADR, >5mm PDR, and PDR compared to those in the unqualified-AI group.
Cohen's kappa analysis revealed high agreement between expert raters, clinical scoring, and e-BBPS (ranging from 0.7791 to 0.8322). However, the agreement between general endoscopists and other raters was only low to moderate (0.2937 to 0.6071). Fleiss' kappa also indicated that the overall agreement among all raters was only 0.575 (p < 0.001, 95% CI 0.574, 0.575), while the Fleiss' kappa for Expert and Clinical scoring, as well as Expert, Clinical scoring, and e-BBPS were 0.809 (p < 0.001, 95% CI 0.807, 0.810) and 0.800 (p < 0.001, 95% CI 0.799, 0.801), respectively.

Conclusion

This study validates the e-BBPS bowel preparation evaluation threshold, confirming that patients with a score of ≤3 have adequate bowel preparation for detecting >5mm adenomatous polyps, while those with a score of >3 require repeat bowel preparation. This conclusion supports the implementation and promotion of fully automated bowel preparation assessment systems, which may improve the objectivity of bowel preparation evaluation and standardize clinical practice for screening colonoscopies in the future.

Introduction

The effectiveness of H. pylori treatment decreases as eradication failures accumulate; however, bismuth quadruple therapy with the single-capsule has shown optimal results not only in first but also in second and subsequent lines of treatment, even in patients with dual clarithromycin and metronidazole resistant strains.

Aims & Methods

To evaluate the use and effectiveness of the single-capsule bismuth quadruple therapy when empirically prescribed as retreatment, despite one or multiple previous eradication failures with the same treatment.
All patients registered at e-CRF AEG-REDCap as part of the European Registry on H. pylori management (Hp-EuReg) from 2013 to 2023, who had received single-capsule therapy in at least 2 different treatment lines (not necessarily consecutive), were analyzed.

Results

Out of 2,579 patients treated with the single-capsule from 2^nd to 6^th rescue treatment line, 101 cases received again the same single-capsule therapy at least in 2 different treatment lines: 67 re-treatments in 2^nd line having previously failed in 1^st line with the single-capsule; 16 re-treatments in 3^rd line (of which 12 had previously received this same therapy in 2^nd line); 11 in 4^th line (previously having failed the same therapy in either 1^st , 2^nd or 3^rd line); 4 in 5^th line; and further 3 in 6^th line (Table). The effectiveness of bismuth quadruple therapy as single-capsule when empirically prescribed repeatedly in 2^nd line was over 90%, and achieved almost 80% in all cases retreated in 3^rd line.

Conclusion

The empirical administration of bismuth quadruple therapy as single-capsule when prescribed as re-treatment in 2^nd line after previous failure with the same therapy achieves optimal effectiveness (>90%).

Disclosure

Javier P. Gisbert has served as speaker, consultant, and advisory member for or has received research funding from: Mayoly, Allergan/Abbvie, Diasorin, Richen, Juvisé and Biocodex.
Olga P. Nyssen received research funding from: Mayoly, Allergan/Abbvie, Richen, Juvisé and Biocodex.