Background Recurrence after surgery to treat Crohn's disease is frequent and unpredictable. The efficacy of postsurgery capsule endoscopy in detecting recurrence in patients with Crohn's disease is ...yet to be confirmed. Objective To assess the safety, accuracy, and therapeutic impact of capsule endoscopy in these patients. Design Crohn's disease recurrence at the neoileum (Rutgeers score) was assessed in the patients by colonoscopy and capsule endoscopy. The M2A Patency Capsule (Given Imaging, Yoqneam, Israel) was administered 1 week before capsule endoscopy. Capsule endoscopy was performed within 2 weeks of colonoscopy. Investigators were blinded to the results of each technique. Patient comfort during the procedures was recorded. Patients Twenty-four patients with Crohn's disease with ileocolonic anastomosis were prospectively included. All patients were asymptomatic and did not receive any prophylactic treatment. Main Outcome Measurements Neoileum recurrence. Results A colonoscopy was performed in all patients, although the neoileum could not be reached in 3 of them. M2A Patency Capsule excretion was delayed in 2 patients; thus capsule endoscopy was given only to 22 patients. Recurrence was visualized with colonoscopy in 6 patients and with capsule endoscopy in 5. Ten additional recurrences were visualized only with capsule endoscopy. Moreover, proximal involvement was detected in 13 patients. Therapeutic management was modified in 16 patients. All patients preferred capsule endoscopy. Conclusions Capsule endoscopy is more effective in the evaluation of recurrence after surgery for Crohn's disease and is better tolerated than colonoscopy. This is of significant therapeutic relevance.
Background ERCP can be associated with serious complications. Difficulty in common bile duct (CBD) cannulation is one of the main risk factors for post-ERCP pancreatitis. The double-guidewire ...technique (DGT) has been considered a promising alternative approach in difficult cannulation situations. Objective To compare the performance of DGT with the standard cannulation technique (SCT) in patients in whom CBD cannulation is difficult to perform. Design Multicenter randomized, controlled trial. Setting Six tertiary referral centers. Patients A total of 188 patients with difficult CBD cannulation defined by completion of 5 unsuccessful cannulation attempts were enrolled. Interventions Ninety-seven patients were assigned to the DGT group and 91 to the SCT group. Both techniques were compared for an extra 10 cannulation attempts. Main Outcome Measurements CBD cannulation rate, number of attempts required to cannulate, and ERCP-related complications. Results Successful CBD cannulation was achieved in 46 of 97 (47%) patients in the DGT group compared with 51 of 91 (56%) in the SCT group (OR 0.85; 95% CI, 0.64-1.12). The median number of attempts required for each group was 9 and 7, respectively ( P = .128). The incidence of post-ERCP pancreatitis was 17% in the DGT group and 8% in the SCT group (OR 2.13; 95% CI, 0.89-5.05). Limitations Reduced number of enrolled subjects and a lack of detailed information regarding the number and extent of pancreatic duct contrast injections. Conclusions In patients with difficult CBD cannulation, DGT was not superior to SCT in achieving CBD cannulation. DGT might be associated with a higher risk of post-ERCP pancreatitis. (This study has been registered in ClinicalTrials.gov with identifier NCT00270868 .)
Background The growing demand for colonoscopies and inappropriate colonoscopies have become a significant problem for health care. Objectives To assess the appropriateness of colonoscopies and to ...analyze the association with some clinical and organizational factors. To compare the results of the European Panel of Appropriateness of Gastrointestinal Endoscopy (EPAGE) and the EPAGE-II criteria. Design Cross-sectional study. Setting Endoscopy unit of a teaching hospital in Spain. Patients Patients referred for colonoscopy, excluding urgent, therapeutic indications, and poor cleansing. Main Outcome Measurements Appropriateness of colonoscopies according to the EPAGE criteria. Results From 749 colonoscopies, 619 were included. Most patients were referred by gastroenterologists (66.1%) in an outpatient setting (80.6%). Hematochezia was the most frequent indication (31.5%) followed by colorectal cancer–related indications (27.3%); a clinically relevant diagnosis was established in 41%. Inappropriate use was higher with EPAGE (27.0%) than EPAGE-II (17.4%) criteria. Surveillance after colonic polypectomy and uncomplicated lower abdominal pain were the indications exhibiting higher inadequacy. Inappropriate use was less with older age, in hospitalized patients, with referrals from internal medicine, and in colonoscopies with clinically relevant diagnoses. Agreement between EPAGE and EPAGE-II was fair (weighted κ = 0.31) but improved to moderate (simple κ = 0.60) after grouping appropriate and uncertain levels. Limitations The appropriateness criteria are based on panel opinions. Some patients (12%) could not be evaluated with the EPAGE criteria. Conclusions Our study identifies substantial colonoscopy overuse, especially in tumor disease surveillance. The EPAGE-II criteria decrease the inappropriate rate and the possibility of overlooking potentially severe lesions.
