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Aim The use of artificial intelligence represents an objective approach to increase endoscopist's adenoma detection rate (ADR) and limit interoperator variability. In this study, we evaluated a newly developed deep convolutional neural network (DCNN) for automated detection of colorectal polyps ex vivo as well as in a first in-human trial. Methods For training of the DCNN, 116 529 colonoscopy images from 278 patients with 788 different polyps were collected. A subset of 10 467 images containing 504 different polyps were manually annotated and treated as the gold standard. An independent set of 45 videos consisting of 15 534 single frames was used for ex vivo performance testing. In vivo real-time detection of colorectal polyps during routine colonoscopy by the DCNN was tested in 42 patients in a back-to-back approach. Results When analyzing the test set of 15 534 single frames, the DCNN's sensitivity and specificity for polyp detection and localization within the frame was 90% and 80%, respectively, with an area under the curve of 0.92. In vivo, baseline polyp detection rate and ADR were 38% and 26% and significantly increased to 50% (P = 0.023) and 36% (P = 0.044), respectively, with the use of the DCNN. Of the 13 additionally with the DCNN detected lesions, the majority were diminutive and flat, among them three sessile serrated adenomas. Conclusion This newly developed DCNN enables highly sensitive automated detection of colorectal polyps both ex vivo and during first in-human clinical testing and could potentially increase the detection of colorectal polyps during colonoscopy.

Contains fulltext : 220020.pdf (Publisher’s version ) (Closed access) BACKGROUND: Patient satisfaction is a crucial indicator of gastrointestinal endoscopy quality. The gastrointestinal endoscopy satisfaction questionnaire (GESQ) was validated for the assessment of patient satisfaction undergoing endoscopy in English with good validity. We translated and validated the GESQ in Dutch. METHODS: The original GESQ was translated in Dutch according to the WHO guidelines. First, an internal validation of the Dutch GESQ (D-GESQ) was established by the think-aloud method and subsequent expert panel analysis. Next, the D-GESQ was embedded in the computer-based education (CBE) program in our unit, with 30-day interval after endoscopy. Adult patients, informed via CBE after undergone endoscopy, were included. Exclusion criteria were conscious sedation, limited language skills, no e-mail address available, dementia and visual impairment. For statistical analysis, several psychometric analyses were performed to identify the underlying dimensions and assessed the questionnaire for reliability and validity. RESULTS: In total, 227 of 1065 patients completed the D-GESQ, a response rate of 21.3%. Men comprised 52.6% (n = 129) of patients. Mean age was 62.7 ± 11.54 years. In total, 180 patients (79.3%) had previously undergone endoscopy, with 157 (87.2%) of them two or more times. The exploratory factor analysis showed the 21 questions could best be clustered into five clusters instead of four in the original GESQ. The D-GESQ had an overall Cronbach α of 0.88, confirming the high internal validity. CONCLUSION: The Dutch version of the GESQ showed high internal validity and practicality. We recommend the D-GESQ for routine use in endoscopy practice to improve quality of patient care.

Item does not contain fulltext OBJECTIVES: Hepatocellular carcinoma (HCC) usually occurs in patients with cirrhosis, but can also develop in noncirrhotic livers. In the present study we explored associated risk factors for HCC without cirrhosis and compared patient and tumor characteristics and outcomes in HCC patients with and without underlying cirrhosis. METHODS: Patients with HCC diagnosed in the period 2005-2012 in five Dutch academic centers were evaluated. Patients were categorized according to the presence of cirrhosis on the basis of histology or combined radiological and laboratory features. RESULTS: In total, 19% of the 1221 HCC patients had no underlying cirrhosis. Noncirrhotic HCC patients were more likely to be female and to have nonalcoholic fatty liver disease or no risk factors for underlying liver disease, and less likely to have hepatitis C virus or alcohol-related liver disease than did cirrhotic HCC patients. HCCs in noncirrhotic livers were more often unifocal (67 vs. 48%), but tumor size was significantly larger (8 vs. 4 cm). Despite the larger tumors, more patients underwent resection (50 vs. 10%) and overall survival was significantly better than in cirrhotics. In multivariate analyses, absence of cirrhosis [hazard ratio (HR) 0.49, 95% confidence interval (CI) 0.38-0.63] and presence of hepatitis B (HR 0.68, 95% CI 0.51-0.91) were independent predictors for lower mortality, whereas hepatitis C virus was associated with higher mortality (HR 1.32, 95% CI 1.01-1.65). CONCLUSION: HCC without cirrhosis was strongly associated with female sex and presence of nonalcoholic fatty liver disease or no risk factors for underlying liver disease. In absence of cirrhosis, resections were more often performed, with better survival despite larger tumor size.

Background Chronic constipation is a common condition,but the exact impact on healthcare budgets in WesternEurope is poorly documented.Objectives The aim of this study was to (a) investigatechronic constipation-related direct medical costs in patientswith newly diagnosed chronic constipation and (b) studydifferences in costs according to natural history.Patients and methods We identified 16887 patients newlydiagnosed with chronic constipation in a Dutch healthinsurance database (∼1.3 million patients) in 2006–2009.Individuals with chronic constipation were selected on thebasis of chronic laxative use (≥90 days/year) anddiagnostic related groups for chronic constipation. On thebasis of the episodes of laxative use and diagnostic relatedgroups, individuals were categorized as having persistent,episodic, and nonrecurrent disease. Unadjusted costs forlaxatives and hospital care for chronic constipation andconstipation-related comorbidities were assessed andcompared between patients with nonrecurrent, episodic,and persistent disease. Factors associated with costs wereidentified using Cox regression analyses.Results The mean total chronic constipation-related directmedical costs in the first year after diagnosis were€310±845 and consisted of laxatives (45%) and hospitalcare for chronic constipation (26%) as well as constipation-related comorbidities (29%). Costs were highest in patientswith persistent disease (€367±882) compared withpatients with episodic (€292±808) and nonrecurrent(€263±613) disease (P

BACKGROUND: Patients with an increased risk of having colorectal cancer (CRC) should have priority on the colonoscopy list. OBJECTIVE: To investigate whether presenting symptoms of patients referred for colonoscopy could help in identifying patients with an increased risk of CRC. PATIENTS AND METHODS: Between February 2007 and November 2010, random outpatients referred for colonoscopy were asked to fill out a questionnaire with respect to symptoms for which the colonoscopy was performed. Informed consent was obtained to review the colonoscopy and histology reports. Multivariate logistic regression was performed to identify predictors for CRC. RESULTS: In total, 1458 (21%) patients returned the questionnaire, of whom 925 (63.4%) had undergone previous sigmoidoscopy or colonoscopy. CRC was detected in 41 patients (2.8%). Age over 50 years [adjusted odds ratio (aOR) 3.00; 95% confidence interval (CI) 1.30-6.91] and presenting symptoms of rectal blood loss (aOR 4.62; 95% CI 2.31-9.22) and a change in bowel habits (aOR 3.33; 95% CI 1.50-7.40) were associated independently with an increased risk of finding CRC. Previous sigmoidoscopy or colonoscopy (aOR 0.24; 95% CI 0.12-0.49) and fatigue as presenting symptoms (aOR 0.22; 95% CI 0.09-0.56) were associated with a decreased risk of CRC. Weight loss, self-reported anemia, and abdominal pain were not associated with CRC in this study. CONCLUSION: Patients presenting with rectal blood loss, change in bowel habits, and those older than 50 years of age have an increased risk of a finding of CRC during colonoscopy. We recommend that these risk groups should be prioritized on the colonoscopy list over patients who have undergone a previous endoscopy or who are presenting with fatigue.

Background Colorectal cancer (CRC) associated with Lynch syndrome usually presents at a relatively young age. The Revised Bethesda Guidelines advise screening for Lynch syndrome in patients diagnosed with CRC and a positive family history (FH) of CRC and other Lynch-related cancers.Objective To evaluate recording of the FH and identify factors associated with recording in young patients with CRC.Patients and methods In one academic and two nonacademic hospitals, of all patients diagnosed with CRC at the age of 60 years or younger between 1999 and 2007, electronic medical records were evaluated for a recorded FH of CRC and other Lynch-related cancers. Patient and tumor characteristics were retrieved from the Dutch Comprehensive Cancer Centre and the Dutch Pathological Archive.Results A total of 676 patients were identified. FH was recorded in 395/676 (58%) patients. From 1999 to 2007, recording improved with an odds ratio (OR) of 1.10 [95% confidence interval (CI) 1.03-1.17] per year. Stage III CRC (OR 1.71, 95% CI 1.07-2.75) and administration of chemotherapy (OR 1.84, 95% CI 1.17-2.89) were associated with recording in multivariate analysis. Other factors, including age at diagnosis, sex, surgery, radiotherapy, proximal tumor localization, poor differentiation, and mucinous histology, were not associated with recording.Conclusion A FH of CRC and other Lynch-related cancers was not recorded in B40% of young CRC patients and recording improved only slightly over the years. As a first step in the identification of Lynch-related cancer families, physicians should be trained to record a detailed FH in the work-up of all newly diagnosed CRC patients. Eur J Gastroenterol Hepatol 25:482-487 (C) 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. European Journal of Gastroenterology & Hepatology 2013, 25:482-487

Background and study aims Endoscopic drainage [i.e. conventional, endoscopic ultrasonography (EUS)-assisted, or EUS-guided] is an accepted treatment modality for symptomatic peripancreatic fluid collections (PFC), but data on the efficacy and safety of EUS-guided drainage performed in a large patient cohort are not widely available. Our aim was to evaluate the clinical success and complication rate of EUS-guided drainage of PFCs and to identify prognostic factors for complications and recurrence of PFCs. Patients and methods A retrospective analysis was carried out of consecutive patients undergoing EUS-guided drainage of a symptomatic PFC in the period 2004-2011. Technical success was defined as the ability to enter and drain a PFC by the placement of one or more double-pigtail stents, whereas clinical success was defined as complete resolution of a PFC on follow-up computed tomography. Results In total, 108 patients [56% men, mean age 55 (SD 14) years], underwent EUS-guided drainage of a symptomatic PFC. The procedure was technically successful in 105/108 (97%) patients and a median of 2 (range 1-3) pigtail stents were placed. Clinical success was observed in 87/104 (84%) patients after a median follow-up of 53 (interquartile range 21-130) weeks, whereas PFC recurrence was noted in 15/83 (18%) patients. Complications occurred in 21/105 (20%) patients and procedure-related mortality was not observed. Prognostic factors for complications and recurrence of PFCs could not be identified. Conclusion EUS-guided drainage of PFCs is effective in the majority of patients. Although the complication rate of the procedure is not negligible (20%), they could be managed in almost all patients by conservative and/or endoscopic means and did not result in mortality. (C) 2013 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins

Contains fulltext : 89146.pdf (Publisher’s version ) (Closed access) BACKGROUND: During the treatment of hepatitis C, anaemia may necessitate pegylated-interferon and ribavirin dose reductions with reduced sustained viral response rates. Although erythropoietic growth factors are frequently used to improve anaemia, it is controversial whether endogenous erythropoietic response is insufficient under these circumstances. We aimed to identify risk factors for more pronounced anaemia and to evaluate endogenous erythropoietic response during antiviral therapy. METHODS: One hundred and forty-five naive chronic hepatitis C patients on pegylated-interferon-ribavirin treatment were evaluated for haemoglobin, haematocrit, serum ribavirin and erythropoietin levels. RESULTS: About 99% of patients developed anaemia, with maximal decrease in haemoglobin of 2.5 +/- 1.0 mmol/l (range 0.3-5.5 mmol/l). Older age, lower baseline creatinine clearance, higher baseline haemoglobin, more pronounced haemoglobin decrease after 2 weeks and higher week 24 serum ribavirin concentrations were independent risk factors for more pronounced anaemia. Serum erythropoietin levels increased from median 12 IU/l (range 4-63 IU/l) at baseline to 41 IU/l (range 12-683 IU/l) after 12 weeks of therapy and to 43 IU/l (range 7-3238 IU/l) at week 24 (P

The prognosis of patients with oesophageal cancer is poor, with an overall 5-year survival rate below 15%. The best chance for cure of patients with oesophageal cancer is surgical resection. However, more than 50% of patients have inoperable disease and can only be palliated for dysphagia. Some of these patients participate in studies investigating the activity of single-agent or combination chemotherapy. We report a patient who was cured of metastatic adenocarcinoma in Barrett's oesophagus by six courses of ifosfamide, a chemotherapeutic agent with little or no activity in other patients with adenocarcinoma of the oesophagus or gastro-oesophageal junction. After a follow-up of 13 years and 7 months, no evidence of tumour recurrence was found, while biopsies from the Barrett's oesophagus revealed only low-grade dysplasia. This case obviously raises the question as to how patients with inoperable oesophageal carcinoma can sometimes be cured by chemotherapy alone.

Objective To identify patients who were most at risk of developing spontaneous bacterial peritonitis and who might benefit from selective intestinal decontamination. Design Prospective analysis of all patients admitted with liver cirrhosis during a 4-year period who had ascitic fluid analysis and appropriate bed-side inoculation of ascites in blood culture bottles. Setting Liver transplantation centre in a university hospital. Patients Thirty-one positive episodes and 92 negative episodes of spontaneous bacterial peritonitis were analysed and compared in 83 patients. Results The 1-year survival rate after spontaneous bacterial peritonitis was 14% compared with 43% in the group without spontaneous bacterial peritonitis. The calculated recurrence rate was 20%. The Child—Pugh classification and coagulation parameters were identified as predictive factors for the development of spontaneous bacterial peritonitis as was a deterioration in values for liver function tests. The total ascitic fluid protein content was not predictive. Sclerotherapy for oesophageal varices may also be a predictive factor, but this requires further investigation. Conclusions On the basis of our results, we recommend the use of selective intestinal decontamination for patients with liver cirrhosis Child—Pugh class C and ascites who develop rapidly progressive deterioration of liver function tests, patients who survived a first episode of spontaneous bacterial peritonitis and those awaiting liver transplantation.