COLON: Innovations 3 steps, 3 parts….. · 2017. 10. 13. · COLON: Innovations 3 steps, 3 parts….. Detection: I see an abnormality (usually a polyp) Characterization: Is this

COLON: Innovations3 steps, 3 parts…..

Detection: I see an abnormality (usually a polyp)

Characterization: Is this abnormality neoplastic ?(for example: an adenoma)

Treatment: it is neoplastic. Can I treat it using endoscopy ?

COLON: Innovations

Detection

Characterization

Treatment

COLON: Innovations

Detection

Characterization

Treatment

DetectionDetection: innovations: innovations

…………..2 different approaches..2 different approaches

IMAGE QUALITYIMAGE QUALITY

TOLERANCETOLERANCEto improve the pt compliance to to improve the pt compliance to screening (mass screening or screening (mass screening or individual screening)individual screening)





How to improve How to improve patient tolerance ?patient tolerance ?

New colonoscopesNew colonoscopes= mechanical part of the endoscope has = mechanical part of the endoscope has been modifiedbeen modifiedto facilitate insertion (and visualization)to facilitate insertion (and visualization)

11-- AerAer--OO--scopescope22-- ColonosightColonosight33-- InvendoInvendo44-- EthiconEthicon55-- NeoguideNeoguide66-- ShapelockShapelock77-- Spiral overtubeSpiral overtube88-- VideocapsuleVideocapsule

Is it possible to classify them ?Is it possible to classify them ?

We must take into account We must take into account the mass screening process:the mass screening process:How is mass screening organized ?How is mass screening organized ?

Mass screening of CRCMass screening of CRC= 2 tests= 2 tests

first test: FOBT, first test: FOBT, …………

second test: colonoscopysecond test: colonoscopyif first test positiveif first test positive

Some could replace the first test Some could replace the first test EthiconEthiconAerAer--OO--scopescopeCapsuleCapsule

because they have no therapeutic capabilities (no because they have no therapeutic capabilities (no operating channel)operating channel)

Some could replace the second test: Some could replace the second test: InvendoInvendoNeoguideNeoguideColonosight Colonosight

Overtube: Overtube: ShapelockShapelockSpiral overtube Spiral overtube

Abandoned





Vucelic Gastroenterology 2006:10 caecal intubations /12

Almost abandoned





European study320 pts

All polyps >6mm >10mm

Sensitivity 73% 64% 60%Specificity 77% 84% 98%PPV 86% 60% 83%NPV 59% 86% 93%

Bowel cleansing: grade good and above

Capsule Colo

Total 72% 87%Sigmoid 70% 87%Descending 77% 86%Transverse 74% 86%Ascending 69% 83%Caecum 61% 81%





LEDOperating channel

Remote control

Single-usecolonoscope

Pneumaticbending

Rösch GIE 200834 patients82% caecal intubation

LEDOperating channel

Remote control

Single-usecolonoscope

Pneumaticbending

Uncertain future





NeoGuide Endoscopy System

AbandonedDevelopment for« NOTES »

EickhoffAm J Gastro 200710 caecal intubations / 11



Some could replace the second test: Some could replace the second test: InvendoInvendoNeoguideNeoguideColonosight Colonosight -- STRYKER STRYKER


Pneumatic propellerLEDSingle use sheath

Almost AbandonedOnly focused on single use sheath

Improving pt toleranceImproving pt tolerancenew colonoscopes: new colonoscopes: ConclusionConclusion

Very disappointingVery disappointing

Capsule: almost the last productCapsule: almost the last productMain problem with capsule = bowel Main problem with capsule = bowel cleansingcleansing





IMAGE QUALITY : innovationsIMAGE QUALITY : innovations

Virtual chromoscopyVirtual chromoscopy

AutofluorescenceAutofluorescence

Image enlargementImage enlargement





White light

NBI

Narrow band imaging Spectrum

Adenoma Detection

Adenoma detection - Randomised

65

23

72

51

67

17

60

44

01020304050607080

Rex Adler East Kalten-bach

% w

ith 1

+ ad

enom

as

NBI

WhiteLight

Rex D et al GIE 2006Rex D et al GIE 2006Adler A Adler A et al.et al. Gut 08 Gut 08 East JE East JE et al.et al. DDW 07DDW 07Kaltenbach TR Kaltenbach TR et al.et al. DDW 07DDW 07

Inoue T J Gastro 2008: 243 pts, No effect

HNPCC

Proportion flat adenomas

12%

45%

0%

10%

20%

30%

40%

50%

Prop

ortio

n fla

t ade

nom

as

White lightNBI

P=.039/21

3/25

Adenoma detection - proximal colon

27%

42%

0%5%

10%15%20%25%30%35%40%45%

At l

east

one

ade

nom

a

White lightWL + NBI

P=.004

East JE East JE et al.et al.Gut 08Gut 08

NBI

NBI

WL

Detection DALMs in ColitisNBI can detect and characterise DALMsNot better than white light

East East et al.et al. Gut 2006;55:1432Gut 2006;55:1432--3535Dekker Dekker et al.et al. Endoscopy 2007;39:216Endoscopy 2007;39:216--2121

NBI: detection

Average risk populationIs virtual chromoendoscopy recommended as the standard for CCR screening ? No.

High risk population: HNPCCCan NBI replace chromoendoscopy? PossiblyYes

High risk population: UC surveillanceCan NBI replace chromoendoscopy ? No

Fujinon Intelligent Colour Enhancement (FICE) ?

• Patients presenting for routine colonoscopy were randomly assigned to FICE or white light with targeted chromoscopy (indigo carmine).

• 871 pts• Adenomas: 236 FICE vs 271 white light

Pohl et al. DDW 2008





Juntendo University

Autofluorescence Autofluorescence ColonColon

AFI

AFI

Matsuda Am J Gastroenterol167 pts, random AFI vs WL+ 34% adenomas

HoweverSome disappointements





= To better see behind the folds

Wide angle colonoscope Wide angle colonoscope

standard 140standard 140°°

210210°

Rex Am J Gastro 2003Rex Am J Gastro 2003Deenadayalu Am J Gastro 2004Deenadayalu Am J Gastro 2004

Pb = No effect on miss ratesPb = No effect on miss rates

Third eye

Third eye: pilot study

100 pts

+ 17.6% polyps+ 12.3% adenomas

Waye GIE 2008 AB101

Image quality: ConclusionImage quality: Conclusion

NBI and FICE: limited roleNBI and FICE: limited role

Autofluorescence: uncertainAutofluorescence: uncertain

Image enlargement: interesting field but Image enlargement: interesting field but japanese companies not so interestedjapanese companies not so interestedWhy ?Why ?

COLON: Innovations

Detection

Characterization

Treatment

Can we replace biopsies ?

Can we let in place a polyp ?

Can we orientate the management (IBD ?)

CHARACTERIZATION : innovationsCHARACTERIZATION : innovations


EndocystoscopyEndocystoscopy

Confocal microscopyConfocal microscopy

NBI: pit pattern (such as for chromoscopy)

Hirata , GIE 2007

Hyperplastic Adenoma Carcinoma

NBI can also permit to analyze the vascular pattern ......(not possible with chromo)

NBI: vascular patternHyperplasticWeak vascularpattern

Adenoma: strong vascular pattern

Polyp number

Sensitivity Specificity

Chiu Gut 2007* 180 87-95 % 72-88 %Su Am J Gastro 2006*† 110 96 88Hirata GIE 2007 100 99 94Machida Endoscopy 2004 43 100 75East GIE 2007 33 77-91 50-60Tischendorf Endosc 2007 200 90-94 89-89

NBI: Adenoma vs hyperplastic polyp?NBI: Adenoma vs hyperplastic polyp?

From all these data concerning NBI, From all these data concerning NBI,

If we say type II = hyperplastic polyp,If we say type II = hyperplastic polyp,we have we have 6%6% of risk that the polyp is adenomatousof risk that the polyp is adenomatous

If we say type III = adenomatous polyp,If we say type III = adenomatous polyp,we have we have 16%16% of risk that the polyp is hyperplasticof risk that the polyp is hyperplastic

chromoendochromoendo NBINBI

Risk to miss adenomaRisk to miss adenoma 13%13% 6%6%Risk to miss hyperplastic.Risk to miss hyperplastic. 25%25% 16%16%





Endocytoscopy system ×450Background mucosa

Endocytoscopy system ×450Cancer





Light Guide

Confocal Imaging Window

Biopsy Channel

CCD

Light Guide

Air/Water Nozzles

Auxiliary WaterJet Channel


Ileum

Kiesslich

Hyperplasia

Kiesslich

Adenoma

Kiesslich

Colonic cancer

Kiesslich

Cancer in-situ

Kiesslich

Mild UC

Kiesslich

Severe UC

Kiesslich

Kiesslich Gastroenterol 2007Kiesslich Gastroenterol 2007

Diagnosis of neoplastic changes on IBDDiagnosis of neoplastic changes on IBDAccuracy = 97.8%Accuracy = 97.8%10 fold reduction of the number of biopsies10 fold reduction of the number of biopsies

Hurstone Clin Gastroenterol Hepatol 07, Gut 08Hurstone Clin Gastroenterol Hepatol 07, Gut 08

Kappa coefficient of agreement between endomicroscopy and histopathology: 0.91 Accuracy: 97%2.5 fold increase of the dg yield / chromoscopy

Characterization: ConclusionCharacterization: Conclusion

NBI :NBI : promising to characterize polypspromising to characterize polypsbut is it helpful ? (ex: serrated adenomas)but is it helpful ? (ex: serrated adenomas)

Endomicroscopy:Endomicroscopy: to be evaluatedto be evaluated

Confocal microscopy:Confocal microscopy:Very effective in IBD in expert handsVery effective in IBD in expert handsBut needs confirmation in routine But needs confirmation in routine

COLON: Innovations

Detection

Characterization

Treatment

Last advance = Endoscopic submucosal dissection(ESD)

IT knife Needle knife

Flex knife Hook knife

En bloc resection 97.7% (209/214)Curative resection 89.7% (192/214)

Perforation 7.0% (15/214)0.9% (2/214): surgDelayed Perforation3.7% (8/214)Delayed bleeding

Results of Colorectal ESD

Apr. 2005-Jan.2008, Toranomon Hospital

0% (0/214)Local recurrence

RESULTSRESULTS OF ESDNbr en-bloc R0 Perf CR

TANAKA 70 80% 10% 100%GIE 07 FUJISHIRO 35 88% 63% 6% 100%GIE 06TAMAGAI 105 99% 1%UEGW07Lyon 16 75% 44% 12%

Do we all need to learn and perform ESD for colorectal adenomas ?

Main advantage of ESD

= resection is aiming R0

AdenomaAdenoma

Aiming R0 Not aiming R0

AdenomaAdenoma

Fragments = pieceFragments = piece--mealmealNot aiming R0Not aiming R0

Aiming R0Aiming R0

piece-meal

Which are the 2 consequences to do not get a R0 resection ?

1- Risk of « recurrence » = 30%Rate increased

with diameterwith piece-meal in comparison to one piece

Kaltenbach GIE 07, Hurlstone Gut 04, Tamura Endosc 04, Tanaka GIE01, Su AJG 05, Sano Dig Endosc 04

FOLLOW-UP to be organized

Balance

Perforation riskProcedure duration Need for follow-up

Looking for perfection is maybe not the more cost-effective approach……

Which are the 2 consequences to let in place adenomatous tissue ?

2- Risk to let in place or to have destroyed carcinoma

AdenomaAdenoma

Invasive carInvasive car

FragmentsFragments

AdenomaAdenoma

Invasive carInvasive car

In which cases do we need to aim to have a R0 resection ?

2 CLASSIFICATIONS to be known

Paris classificationmacroscopy, general pattern

Kudo classificationmacroscopy, pitt pattern

Polypoïd

Flat

Ulcerated

0-Ip 0-Issessilepedunculated

surelevated flat depressed0-IIa 0-IIb 0-IIc

0-III

IIc + IIa IIa + IIc

Complex patterns

LST = Is + IIc

II a + II c

II c + II a

0

20

40

60

80

100

120

0-I 0-II a 0-II b 0-II c III

Oeso

Stomach

Colon

Submucosal invasion

2 CLASSIFICATIONS to be known

Paris classificationmacroscopy, general pattern

Kudo classificationmacroscopy, pitt pattern

IIILIIIS IV

Small tubularSmall tubular large tubularlarge tubular branchedbranched

adenoma

VI VN

irregularirregular Non structuredNon structured

carcinoma

In which cases do we need to aim to have a R0 resection ?

Ulcerated0-III

Reference = surgery

Endoscopyonly if aiming R0

If Kudo type VReference = surgeryEndoscopy only if aiming R0

0-IIc

IIc + IIa

IIa + IIcLST = Is + IIc

II a + II c

II c + II a

Treatment: conclusion on ESD

Adenoma = cost-effectiveness analyzis is requiredSuspicion of invasive adenocar = ESD to be recommended (Kudo V, depressed or complex Paris)

At least, excellent technique to improve material and skillfulness

GENERAL CONCLUSION

Numerous innovationsDifferent aims: needs to be classified (detection, characterization)

Frequently disappointing

Will not replace good practice (ex: adenoma detection rate, biopsies, EMR)

Documents

COLON: Innovations 3 steps, 3 parts….. · 2017. 10. 13. · COLON: Innovations 3 steps, 3 parts….. Detection: I see an abnormality (usually a polyp) Characterization: Is this