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Background and Aims: Add-on devices have been widely used in clinical practice. The aim of this meta-analysis was to compare the adenoma detection rate between Endocuff-assisted colonoscopy (EAC) and cap-assisted colonoscopy (CAC)., Methods: PubMed, EMBASE, SCOPUS, and Cochrane databases were searched. Outcomes included adenoma detection rate, cecal intubation rate, cecal intubation time, and withdrawal time. Dichotomous data were pooled to obtain the odds ratio or risk ratio. Continuous data were pooled using the mean difference., Results: Of the 240 articles reviewed, six randomized controlled trials were included, with a total of 1994 patients. In the meta-analysis, no statistical difference in adenoma detection rate was detected between EAC and CAC (47.0% vs 45.1%; P = 0.33). EAC significantly improved detection rate of diminutive adenomas/polyps compared with CAC (P = 0.01). Cecal intubation was achieved in 96.5% in EAC group and 97.9% in CAC group (P = 0.04). Besides, no statistical difference was found in cecal intubation time (P = 0.86), withdrawal time (P = 0.88), small adenomas/polyps (P = 0.60), or large adenomas/polyps (P = 0.95)., Conclusion: EAC and CAC have their respective merits. EAC significantly improve the detection of diminutive adenomas/polyps. CAC was better in cecal intubation rate., (© 2020 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aims: Quality control can decrease variations in the performance of colonoscopists and improve the effectiveness of colonoscopy to prevent colorectal cancers. Unfortunately, routine quality control is difficult to carry out because a practical method is lacking. The aim of this study was to develop an automatic quality control system (AQCS) and assess whether it could improve polyp and adenoma detection in clinical practice., Methods: First, we developed AQCS based on deep convolutional neural network models for timing of the withdrawal phase, supervising withdrawal stability, evaluating bowel preparation, and detecting colorectal polyps. Next, consecutive patients were prospectively randomized to undergo routine colonoscopies with or without the assistance of AQCS. The primary outcome of the study was the adenoma detection rate (ADR) in the AQCS and control groups., Results: A total of 659 patients were enrolled and randomized. A total of 308 and 315 patients were analyzed in the AQCS and control groups, respectively. AQCS significantly increased the ADR (0.289 vs 0.165, P < .001) and the mean number of adenomas per procedure (0.367 vs 0.178, P < .001) compared with the control group. A significant increase was also observed in the polyp detection rate (0.383 vs 0.254, P = .001) and the mean number of polyps detected per procedure (0.575 vs 0.305, P < .001). In addition, the withdrawal time (7.03 minutes vs 5.68 minutes, P < .001) and adequate bowel preparation rate (87.34% vs 80.63%, P = .023) were superior for the AQCS group., Conclusions: AQCS could effectively improve the performance of colonoscopists during the withdrawal phase and significantly increase polyp and adenoma detection. (Clinical trial registration number: NCT03622281.)., (Copyright © 2020. Published by Elsevier Inc.)

Objective: We aimed to investigate the efficacy of a split-dose 4-L polyethylene glycol (PEG) regimen for the quality of bowel preparation in Asian patients with previous colorectal surgery for colorectal cancer (CRC)., Methods: This was a prospective, single-center, randomized controlled, endoscopist-blinded study. Patients with previous colorectal surgery for CRC were randomly allocated to a routine, morning-only 2-L PEG (2-MO) group or a split-dose 4-L PEG (4-SD) group. The primary outcome was a successful bowel preparation rate. Secondary outcomes were polyp detection rate (PDR), adenoma detection rate (ADR), patient compliance, satisfaction, tolerance, willingness to repeat the preparation and difficulty of the bowel preparation process., Results: In total, 187 patients were included (93 in the 2-MO group, 94 in the 4-SD group) in this study. The rate of successful bowel preparation in the 4-SD group was higher than in the 2-MO group (89.4% vs 66.7%, P < 0.001) in an intention-to-treat analysis according to the Aronchick score. Patients' satisfaction with the bowel preparation process in the 4-SD group was superior to that in the 2-MO group (93.4% vs 82.2%, P = 0.021). No significant differences were detected in PDR, ADR, patient compliance, tolerance, willingness to repeat the preparation or difficulty of the bowel preparation process., Conclusions: The 4-SD PEG regimen was superior to a routine, morning-only 2-L PEG preparation for bowel preparation in an Asian population with previous colorectal surgery., (© 2018 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd.)

Background and Study Aims: Ideal bowel preparation for colonoscopy requires complete removal of fluid and foam from the colon. Polyethylene glycol (PEG) is widely used for bowel preparation, with antifoaming agents such as simethicone commonly used in combination with PEG. Data on the effect of simethicone on the adenoma detection rate (ADR) were limited. This study therefore aimed to investigate whether preprocedure simethicone could increase the ADR., Patients and Methods: This was a prospective, multicenter, endoscopist-blinded randomized controlled trial involving consecutive patients who underwent colonoscopy in six centers in China. Patients were randomly assigned to one of two groups: PEG plus simethicone or PEG alone. The primary outcome was ADR; secondary outcomes were quality of bowel preparation, measured by the Boston bowel preparation scale (BBPS) and bubble scores., Results: 583 patients were included. More adenomas were detected in the PEG plus simethicone group than in the PEG alone group (ADR 21.0 % vs. 14.3 %, P  = 0.04; advanced ADR 9.0 % vs. 7.0 %, P  = 0.38). The mean number of adenomas detected was 2.20 ± 1.36 vs. 1.63 ± 0.89 ( P  = 0.02). Patients in the PEG plus simethicone group showed better bowel cleansing efficacy: BBPS ≥ 6 in 88.3 % vs. 75.2 % ( P  < 0.001) and bubble scores of 1.00 ± 1.26 vs. 3.98 ± 2.50 ( P  < 0.001). Abdominal bloating was reported less frequently in the PEG plus simethicone group (7.8 % vs . 19.7 %, P  < 0.001) than in the PEG alone group., Conclusion: Combined use of PEG and simethicone is associated with a significantly increased ADR in a Chinese population., Competing Interests: None, (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and study aims  Interval colorectal cancers detected after screening colonoscopy are more likely to be associated with missed lesions in the proximal colon. The aim of this study was to determine whether segmental re-examination of the proximal colon could increase the proximal adenoma detection rate (ADR) and to evaluate the time-effectiveness of this approach. Patients and methods  Patients undergoing colonoscopy were recruited into the prospective randomized controlled study. They were randomly assigned to the segmental re-examination group, in which the proximal colon was examined twice segmentally, and a control group in which the withdrawal time was extended (EWT). Detection rates were calculated and compared for all polyps and adenomas in both the proximal colon and the whole colon. Withdrawal times were recorded and compared. Results  A total of 360 patients were included in the study (re-examination 178 vs. EWT 182). The proximal ADR in the re-examination group was higher than that in the EWT group (33.1 % vs. 23.6 %; P  = 0.045). More proximal adenomas were detected per patient in the re-examination group (0.54 vs. 0.36; P  = 0.048). The ADR of the whole colon was similar in the two groups. Proximal withdrawal time was also similar (re-examination 4.29 ± 1.23 minutes vs. EWT 4.34 ± 1.36 minutes; P  = 0.74). In addition, there was no statistically significant difference in the total duration of the colonoscopy between the two groups. Conclusions  Segmental re-examination of the proximal colon increased the proximal ADR and the number of proximal adenomas detected, and was accomplished easily and safely without increasing the overall examination time., Trial Registration: ClinicalTrials.gov (NCT02581475)., (© Georg Thieme Verlag KG Stuttgart · New York.)

Colonoscopy remains the mainstay in diagnosing and monitoring colorectal cancer and other colorectal lesions. The diagnostic efficiency of colonoscopy greatly depends on the quality of bowel preparation, which is closely associated with the patient's compliance with the preparation instructions. In addition, the procedural requirements of bowel preparation are often complex and difficult for patients to comprehend and memorize, especially those with lower health literacy and motivation. Therefore, in recent years, many educational methods have been developed, such as educational booklets, cartoon visual aids, educational videos, short message service, telephone, social media and smart phone applications. These educational methods have significantly improved compliance with the instructions for bowel preparation and ultimately promoted the visualization of the colon in patients undergoing colonoscopy., (© 2017 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd.)

Background: Mesenchymal stem cells (MSCs) have demonstrated significant potentials for the treatment of inflammatory bowel disease. Clinical feasible methods to individually document the MSC recruitment to intestinal mucosa is lacking. Here, we proposed that endomicroscopy could noninvasively track MSCs in vivo at cellular resolution., Method: Isolated Sprague Dawley rat MSC was characterized, fluorescently labeled, and imaged ex vivo using an endomicroscope. Then enhanced green fluorescent protein (eGFP)-labeled MSC was tracked in vivo, and acquired images were compared with immunofluorescence, immunohistology, and fluorescent in situ hybridization results., Results: Endomicroscopy visualized clearly the eGFP-labeled or carboxyfluorescein succinimidyl ester-stained MSC ex vivo. Endomicroscopy using the FIVE1 system could track eGFP-labeled MSC with distinct in vivo features. Immunofluorescence, immunohistochemistry, and fluorescent in situ hybridization confirmed the presence of eGFP-positive cells. In vivo endomicroscopy could quantify the transplanted MSCs that homed to colonic mucosa of the recipient rat in multiple models, including the rat-to-rat allograft, human-to-rat xenograft, hypoxia-induced MSC, and busulfan immunosuppressed recipient rat models. After hypoxia induction, there was a trend of enhanced rat MSC homing to the inflamed mucosa as visualized by endomicroscopy (114.1 in hypoxia group versus 34.3 in other 3 groups combined, t = 2.14, P = 0.0644)., Conclusions: Endomicroscopy is a novel and promising tool to track transplanted MSCs to the colonic mucosa. This clinical available noninvasive cellular tracking method may provide new insight to individualize each recipient's regimen in the future.

Background: i-Scan is a novel virtual chromoendoscopy system designed to enhance surface and vascular patterns to improve optical diagnostic performance. Numerous prospective studies have been done to evaluate the accuracy of i-Scan in differentiating colonic neoplasms from non-neoplasms. i-Scan could be an effective endoscopic technique for optical diagnosis of colonic polyps., Objective: Our aim of this study was to perform a meta-analysis of published data to establish the diagnostic accuracy of i-Scan for optical diagnosis of colonic polyps., Methods: We searched PubMed, Medline, Elsevier ScienceDirect and Cochrane Library databases. We used a bivariate meta-analysis following a random effects model to summarize the data and plotted hierarchical summary receiver-operating characteristic (HSROC) curves. The area under the HSROC curve (AUC) serves as an indicator of the diagnostic accuracy., Results: The meta-analysis included a total of 925 patients and 2312 polyps. For the overall studies, the area under the HSROC curve was 0.96. The summary sensitivity was 90.4% (95%CI 85%-94.1%) and specificity was 90.9% (95%CI 84.3%-94.9%). In 11 studies predicting polyps histology in real-time, the summary sensitivity and specificity was 91.5% (95%CI 85.7%-95.1%) and 92.1% (95%CI 84.5%-96.1%), respectively, with the AUC of 0.97. For three different diagnostic criteria (Kudo, NICE, others), the sensitivity was 86.3%, 93.0%, 85.0%, respectively and specificity was 84.8%, 94.4%, 91.8%, respectively., Conclusions: Endoscopic diagnosis with i-Scan has accurate optical diagnostic performance to differentiate neoplastic from non-neoplastic polyps with an area under the HSROC curve exceeding 0.90. Both the sensitivity and specificity for diagnosing colonic polyps are over 90%.

Background: Assessment of inflammatory activity in patients with ulcerative colitis (UC) is crucial to the prediction of relapse. Confocal laser endomicroscopy (CLE) is an accurate tool for assessing inflammatory activity in UC patients. This study aimed to evaluate whether CLE could be used to predict UC relapse reliably., Methods: In total, forty-three patients with documented UC were analyzed in this study. Patients identified as having obvious active inflammation by conventional colonoscopy were excluded. The mucosa of each patient's sigmoid colon and rectum was assessed by CLE before targeted biopsies were taken. The patients were then followed up for at least 12 months to evaluate relapse according to the Simple Clinical Colitis Activity Index. The correlation between CLE classification and UC relapse was evaluated., Results: Seventeen of 20 patients with histologically confirmed normal or chronic inflammation were diagnosed as having non-active inflammation by real-time CLE and 22 of 23 patients with histologically confirmed acute inflammation were diagnosed as having active inflammation by CLE. The sensitivity, specificity, and accuracy of CLE in real-time diagnosis of active inflammation were 95.7%, 85%, and 90.7%, respectively. The agreement between CLE and conventional histology was excellent (kappa value = 0.812). Two of 18 (11.1%) patients who were classified as having non-active inflammation by CLE relapsed, while 16 of 25 (64%) patients classified as having as active inflammation relapsed. The relapse rate of patients with active inflammation was significantly higher than of those with non-active inflammation (P < 0.001)., Conclusions: CLE is comparable to conventional histology in predicting relapse in patients with UC.

Background and Aims: Three different confocal laser endomicroscopy (CLE) diagnostic systems including Maiz, Sanduleanu, and Qilu had been developed to differentiate between benign and neoplastic colorectal lesions. This study was designed to compare and evaluate these three diagnostic systems by different levels of expertise., Methods: Thirty-nine patients with 50 colorectal polyps, including 23 hyperplastic polyps and 27 adenomas diagnosed by histopathology, were recruited. Four confocal images (two superficial images and two deeper images) and one conventional white-light endoscopic image were selected from each of the 50 lesions in this study by an experienced endomicroscopist. Selected images were evaluated by three experienced CLE investigators and three non-experienced ones. The accuracy and interobserver agreement between experienced and non-experienced investigators for prediction of colorectal neoplasia were determined., Results: The diagnostic accuracy was 84%, 81%, and 87%, respectively, using the Maiz, Sanduleanu, and Qilu diagnostic system, while the sensitivity was 85%, 79%, and 85%, the specificity was 83%, 84%, and 89%, respectively. There is no significant difference on diagnostic accuracy between experienced and non-experienced investigators. In addition, there is a short learning curve for non-experienced CLE investigators identified in this study., Conclusions: The three diagnostic systems for the prediction of colorectal hyperplastic polyp or adenoma have a high accuracy, sensitivity, and specificity. The diagnostic accuracy was not significantly influenced by the expertise in CLE., (© 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.)

Objective: To evaluate the feasibility and accuracy of confocal laser endomicroscopy (CLE) for the in vivo diagnosis of colorectal cancer (CRC) compared with conventional histology., Methods: Consecutive patients who had undergone CLE examination for screening or surveillance colonoscopy were recruited. Suspected malignant lesions and adjacent mucosal sites were first examined by confocal imaging and then biopsied specimens of these sites were obtained. The confocal images were independently interpreted by two endoscopists. The diagnosis made with CLE was compared with the conventional histological diagnosis in a prospective and blinded fashion., Results: In total, 71 patients with suspected malignant lesions were included in the study. A total of 74 lesions and 92 adjacent mucosal sites were observed. The sensitivity, specificity and accuracy of CLE in diagnosing CRC were 97.1%, 99.0% and 98.2% for endoscopist A, and 98.6%, 96.9% and 97.6% for endoscopist B, respectively. The interobserver agreement between the two endoscopists was excellent (κ = 0.950). The accuracy of diagnosing poorly differentiated CRC using CLE was 97.0% for endoscopist A and 95.6% for endoscopist B., Conclusion: CLE has the potential to enable an immediate diagnosis of CRC and the degree of differentiation of CRC during ongoing endoscopy in vivo., (© 2013 The Authors. Journal of Digestive Diseases © 2013 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd.)

No prediction rule is currently available for advanced colorectal neoplasms, defined as invasive cancer, an adenoma of 10 mm or more, a villous adenoma, or an adenoma with high-grade dysplasia, in average-risk Chinese. In this study between 2006 and 2008, a total of 7,541 average-risk Chinese persons aged 40 years or older who had complete colonoscopy were included. The derivation and validation cohorts consisted of 5,229 and 2,312 persons, respectively. A prediction rule was developed from a logistic regression model and then internally and externally validated. The prediction rule comprised 8 variables (age, sex, smoking, diabetes mellitus, green vegetables, pickled food, fried food, and white meat), with scores ranging from 0 to 14. Among the participants with low-risk (≤3) or high-risk (>3) scores in the validation cohort, the risks of advanced neoplasms were 2.6% and 10.0% (P < 0.001), respectively. If colonoscopy was used only for persons with high risk, 80.3% of persons with advanced neoplasms would be detected while the number of colonoscopies would be reduced by 49.2%. The prediction rule had good discrimination (area under the receiver operating characteristic curve = 0.74, 95% confidence interval: 0.70, 0.78) and calibration (P = 0.77) and, thus, provides accurate risk stratification for advanced neoplasms in average-risk Chinese.

Objectives: The assessment of inflammation activity in ulcerative colitis (UC) includes endoscopy and histology. Confocal laser endomicroscopy (CLE) combines real-time endoscopy and histology. This study was aimed at evaluating the application of CLE in the assessment of inflammation activity in UC., Methods: In total, 73 consecutive patients with UC who visited Qilu Hospital for colonoscopy surveillance underwent CLE. Inflammation activity was first assessed by the colonoscopy Baron score, then by CLE with a 4-grade classification of crypt architecture, as well as by analysis of microvascular alterations and fluorescein leakage. Targeted biopsy samples were taken for histological analysis. Stored CLE images were subjected to post-CLE objective assessment., Results: Both assessment of crypt architecture and fluorescein leakage with CLE showed good correlations with histological results (Spearman's rho, both P<0.001). CLE seemed to be more accurate than conventional white-light endoscopy for evaluating macroscopical normal mucosa. More than half of the patients with normal mucosa seen on conventional white-light endoscopy showed acute inflammation on histology, whereas no patients with normal mucosa or with chronic inflammation seen on CLE showed acute inflammation on histology. Assessment of microvascular alterations by CLE showed good correlation with histological findings (P<0.001). On post-CLE objective assessment, subjective architectural classifications were supported by the number of crypts per image (P<0.001) but not fluorescein leakage results by gray scale (P=0.194)., Conclusions: CLE is reliable for real-time assessment of inflammation activity in UC. Crypt architecture, microvascular alterations, and fluorescein leakage are promising markers in CLE evaluation.

Background and Study Aims: Ideal bowel preparation for colonoscopy requires complete removal of fluid and foam from the colon. Polyethylene glycol (PEG) is widely used for bowel preparation, with antifoaming agents such as simethicone commonly used in combination with PEG. Data on the effect of simethicone on the adenoma detection rate (ADR) were limited. This study therefore aimed to investigate whether preprocedure simethicone could increase the ADR.Patients and Methods: This was a prospective, multicenter, endoscopist-blinded randomized controlled trial involving consecutive patients who underwent colonoscopy in six centers in China. Patients were randomly assigned to one of two groups: PEG plus simethicone or PEG alone. The primary outcome was ADR; secondary outcomes were quality of bowel preparation, measured by the Boston bowel preparation scale (BBPS) and bubble scores.Results: 583 patients were included. More adenomas were detected in the PEG plus simethicone group than in the PEG alone group (ADR 21.0 % vs. 14.3 %, P = 0.04; advanced ADR 9.0 % vs. 7.0 %, P = 0.38). The mean number of adenomas detected was 2.20 ± 1.36 vs. 1.63 ± 0.89 (P = 0.02). Patients in the PEG plus simethicone group showed better bowel cleansing efficacy: BBPS ≥ 6 in 88.3 % vs. 75.2 % (P < 0.001) and bubble scores of 1.00 ± 1.26 vs. 3.98 ± 2.50 (P < 0.001). Abdominal bloating was reported less frequently in the PEG plus simethicone group (7.8 % vs. 19.7 %, P < 0.001) than in the PEG alone group.Conclusion: Combined use of PEG and simethicone is associated with a significantly increased ADR in a Chinese population. [ABSTRACT FROM AUTHOR]

Background and study aims Interval colorectal cancers detected after screening colonoscopy are more likely to be associated with missed lesions in the proximal colon. The aim of this study was to determine whether segmental re-examination of the proximal colon could increase the proximal adenoma detection rate (ADR) and to evaluate the time-effectiveness of this approach. Patients and methods Patients undergoing colonoscopy were recruited into the prospective randomized controlled study. They were randomly assigned to the segmental re-examination group, in which the proximal colon was examined twice segmentally, and a control group in which the withdrawal time was extended (EWT). Detection rates were calculated and compared for all polyps and adenomas in both the proximal colon and the whole colon. Withdrawal times were recorded and compared. Results A total of 360 patients were included in the study (re-examination 178 vs. EWT 182). The proximal ADR in the re-examination group was higher than that in the EWT group (33.1 % vs. 23.6 %; P = 0.045). More proximal adenomas were detected per patient in the re-examination group (0.54 vs. 0.36; P = 0.048). The ADR of the whole colon was similar in the two groups. Proximal withdrawal time was also similar (re-examination 4.29 ± 1.23 minutes vs. EWT 4.34 ± 1.36 minutes; P = 0.74). In addition, there was no statistically significant difference in the total duration of the colonoscopy between the two groups. Conclusions Segmental re-examination of the proximal colon increased the proximal ADR and the number of proximal adenomas detected, and was accomplished easily and safely without increasing the overall examination time.Trial Registration: ClinicalTrials.gov (NCT02581475). [ABSTRACT FROM AUTHOR]

Objectives Confocal laser endomicroscopy ( CLE) consists of endoscope-based CLE ( eCLE) and probe-based CLE ( pCLE). This study aimed to compare e CLE and pCLE in their diagnostic yield in different parts of the gastrointestinal ( GI) tract. Methods Consecutive patients were scheduled for CLE examination due to GI symptoms. All patients were randomly assigned to eCLE or pCLE group and underwent a programmed procedure using one type of CLE. Differences in procedure time, complication rate, CLE image quality and image acquisition feasibility between these two types of CLE for esophagogastroduodenoscopy (EGD) and colonoscopy were calculated. Results Altogether 513 CLE procedures were performed, including 324 EGD and 189 colonoscopy. The procedure time of pCLE was significantly shorter than that of eCLE both in EGD and colonoscopy (16.78 min vs 18.13 min for EGD, P = 0.027; 32.48 min vs 39.89 min for colonoscopy, P < 0.001). No significant difference was found between these two types of CLE in diagnostic utility, including the detection and prediction of histopathological results of the lesions. The CLE image quality of both e CLE and p CLE were comparable in the stomach and colon, but eCLE seemed to be superior to pCLE in examining the esophagus. Colonoscopy using pCLE had a higher complete rate than that of eCLE, although the difference was not statistically significant ( P = 0.065). Conclusions pCLE is more flexible in diagnosing GI diseases with a shorter procedure time than eCLE regardless of comparable diagnostic yields, except the diagnosis of esophageal diseases in which eCLE provides better image quality. [ABSTRACT FROM AUTHOR]