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Background Risk for intraabdominal abscess (IAA) after laparoscopic appendectomy (LA) remains controversial. A 2008 Cochrane Review suggests almost a threefold increase in the incidence of IAA after LA compared with open appendectomy (OA). Methods The authors conducted a retrospective chart review of all appendicitis patients 18 years and older undergoing appendectomy from 1996 to 2007 at one military treatment facility and one civilian hospital in Hawaii. Data collection included demographics, procedure, presence of complicated appendicitis (defined as perforated or gangrenous appendicitis at surgical or pathologic assessment), and presence of postoperative IAA on computed axial tomography (CAT) scan. Results The review identified 2,464 patients with appendicitis. A total of 1,924 LAs (78%) and 540 OAs (22%) were performed. The comparison of laparoscopic and open appendectomies showed no significant differences in the number of postoperative abscesses (2.2% vs 1.9%; p  = 0.74). The patients with a diagnosis of complicated appendicitis were significantly associated with a higher incidence of postoperative abscess formation (67% vs 25%; p  < 0.01), which had an unadjusted odds ratio of 6.1 (95% confidence interval [CI], 3.4–11.0; p  < 0.01). No significant difference in the development of abscess in patients with complicated appendicitis could be found between LA and OA (5.9% vs 4.1%; p  = 0.44). Conclusions No significant difference in the occurrence of IAA after LA versus OA was found. The patients with complicated appendicitis experienced a greater number of IAA than the patients with uncomplicated appendicitis.

Helicobacter pylori is causally associated with gastritis and peptic ulcer diseases. Recent data (meta-analysis) have demonstrated that triple therapy with amoxicillin, clarithromycin, and a proton pump inhibitor has an eradication rate of only 74-76% and new therapeutic protocols may be necessary. The aim of this study was to examine whether adding bovine lactoferrin (bLf) and probiotics (Pbs) to the standard triple therapy for H. pylori infection could improve the eradication rate and reduce side effects. H. pylori infection was diagnosed in 206 patients: in 107 based on an upper endoscopy exam and a rapid urease test, and in 99 by means of the H. pylori stool antigen-test and the C(13) urea breath test (C(13) UBT). The patients were randomized into two groups: 101 patients (group A) underwent standard triple eradication therapy (esomeprazole, clarithromycin, amoxicillin), while 105 patients (group B) underwent a modified eradication therapy (standard triple eradication therapy plus bLf and Pb). Successful eradication therapy was defined as a negative C(13) UBT 8 wk after completion of the treatment. Results were evaluated by intention-to-treat (ITT) and per-protocol (PP) analysis. Data were evaluated and considered positive when P<0.05. At the end of the study 175/206 patients showed negative C(13) UBT results. According to intention-to-treat analysis, the infection was eradicated in 73/101 patients from Group A and in 93/105 from Group B. PP analysis showed 73/96 patients from Group A and 93/101 from Group B to have been successfully treated. More patients from group A than from group B reported side effects from their treatment (P<0.05). The results of our study suggest that the addition of bLf and Pbs could improve the standard eradication therapy for H. pylori infection--bLf serving to increase the eradication rate and Pbs to reduce the side effects of antibiotic therapy.

The aim of this study was to evaluate the influence of on-site cytopathological evaluation on the diagnostic yield of endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) for the differential diagnosis of solid pancreatic masses in an unselected series of consecutive patients. Patients undergoing EUS-guided FNA of solid pancreatic lesions over a 2-year study period were included. Samples were either evaluated on site by a cytopathologist or processed by the endoscopist and sent to the pathology department for evaluation. Diagnostic accuracy for malignancy, number of needle passes, adequate-specimen collection rate, cytological diagnosis, and final diagnosis, and complication rate according to the presence or absence of on-site cytopathologist were evaluated. A total of 182 patients were included. An on-site cytopathologist was available in 95 cases (52.2%). There was no difference between groups in terms of age, sex, location, and size of the lesions. A significantly higher number of needle passes was performed when an on-site cytopathologist was not available (3.5±1.0 vs. 2.0±0.7; P<0.001). The presence of an on-site cytopathologist was associated with a significantly lower number of inadequate samples (1.0 vs. 12.6%, P=0.002), and a significantly higher diagnostic sensitivity (96.2 vs. 78.2%; P=0.002) and overall accuracy (96.8 vs. 86.2%; P=0.013) for malignancy. Three patients developed complications (two acute pancreatitis, one local bleeding), all of them belonging to the group without on-site cytopathology. On-site cytopathological evaluation improves the diagnostic yield of EUS-guided FNA for the cytological diagnosis of solid pancreatic masses. This is associated with a significantly lower number of inadequate samples and a lower number of needle passes.

On the basis of long-term follow-up data from the National Polyp Study, the authors estimate that mortality from colorectal cancer was about 50% lower among patients who had adenomatous polyps removed than in the general population. It has been a long-standing belief that screening for colorectal cancer can affect mortality from the disease in two ways: by detecting cancers at an early, curable stage and by detecting and removing adenomas. 1 Detection of early-stage colorectal cancer has been shown to be associated with a reduction in mortality from colorectal cancer in screening trials. 2 – 4 However, an adenomatous polyp is a much more common neoplastic finding on endoscopic screening. We previously reported that colonoscopic polypectomy in the National Polyp Study (NPS) cohort reduced the incidence of colorectal cancer. 5 An important question is whether the cancers prevented by colonoscopic . . .

In this large study of colorectal-cancer screening, the endoscopist's rate of adenoma detection was associated with the risk of interval colorectal cancer after screening colonoscopy. Colorectal cancers were less likely to be diagnosed between screening examinations when colonoscopies were performed by endoscopists with an adenoma detection rate of 20% or more. In this large study of colorectal-cancer screening, the endoscopist's rate of adenoma detection was associated with the risk of interval colorectal cancer after screening colonoscopy. Although colonoscopy is widely used for colorectal-cancer screening, 1 – 3 its miss rate for cancers and adenomatous polyps (benign premalignant tumors or adenomas), which is low but not negligible, remains a concern. 4 – 6 It has been suggested that a high-quality examination that ensures the detection and removal of all neoplastic lesions is key for screening efficacy. 6 – 8 In response, professional societies have proposed the use of various quality-assessment indicators. Of such indicators, the rates of adenoma detection and cecal intubation are the most commonly used. 7 – 10 However, these measurements have never been validated, and it is not known whether an improvement . . .

Colonoscopy is the best available method to detect and remove colonic polyps and therefore serves as the gold standard for less invasive tests such as virtual colonoscopy. Although gastroenterologists agree that colonoscopy is not infallible, there is no clarity on the numbers and rates of missed polyps. The purpose of this systematic review was to obtain summary estimates of the polyp miss rate as determined by tandem colonoscopy. An extensive search was performed within PUBMED, EMBASE, and the Cochrane Library databases to identify studies in which patients had undergone two same-day colonoscopies with polypectomy. Random effects models based on the binomial distribution were used to calculate pooled estimates of miss rates. Six studies with a total of 465 patients could be included. The pooled miss rate for polyps of any size was 22% (95% CI: 19-26%; 370/1,650 polyps). Adenoma miss rate by size was, respectively, 2.1% (95% CI: 0.3-7.3%; 2/96 adenomas > or =10 mm), 13% (95% CI: 8.0-18%; 16/124 adenomas 5-10 mm), and 26% (95% CI: 27-35%; 151/587 adenomas 1-5 mm). Three studies reported data on nonadenomatous polyps: zero of eight nonadenomatous polyps > or =10 mm were missed (0%; 95% CI: 0-36.9%) and 83 of 384 nonadenomatous polyps <10 mm were missed (22%; 95% CI: 18-26%). Colonoscopy rarely misses polyps > or =10 mm, but the miss rate increases significantly in smaller sized polyps. The available evidence is based on a small number of studies with heterogeneous study designs and inclusion criteria.

In patients with achalasia, symptom reduction at 2 years was not superior with laparoscopic Heller's myotomy (LHM) as compared with pneumatic dilation. Perforation of the esophagus occurred in 4% of patients with pneumatic dilation, and mucosal tears occurred in 12% with LHM. Achalasia is an esophageal motor disorder that is characterized clinically by dysphagia, chest pain, and regurgitation of undigested food. These symptoms result from the absence of esophageal peristalsis combined with a defective relaxation of the lower esophageal sphincter. 1 Currently, treatment consists mainly of endoscopic pneumatic dilation or laparoscopic Heller's myotomy (LHM). For many years, repeated endoscopic pneumatic dilation has been the treatment of choice, leading to therapeutic success in 70 to 80% of cases. 2 With the introduction of minimally invasive surgery, the surgical approach has gained considerable interest, with LHM combined with an antireflux procedure considered to be the procedure . . .

Capsule endoscopy (CE) has demonstrated superior performance compared with other modalities in its ability to detect early small-bowel (SB) Crohn's disease (CD), especially when ileoscopy is negative or unsuccessful. The aim of this study was to evaluate the diagnostic yield of CE compared with other modalities in patients with suspected and established CD using a meta-analysis. A thorough literature search for prospective studies comparing the diagnostic yield of CE with other modalities in patients with CD was undertaken. Other modalities included push enteroscopy (PE), colonoscopy with ileoscopy (C+IL), SB radiography (SBR), computed tomography enterography (CTE), and magnetic resonance enterography (MRE). Data on diagnostic yield among various modalities were extracted, pooled, and analyzed. Data on patients with suspected and established CD were analyzed separately. Weighted incremental yield (IYW) (diagnostic yield of CE-diagnostic yield of comparative modality) and 95% confidence intervals (CIs) of CE over comparative modalities were calculated. A total of 12 trials (n=428) compared the yield of CE with SBR in patients with CD. Eight trials (n=236) compared CE with C+IL, four trials (n=119) compared CE with CTE, two trials (n=102) compared CE with PE, and four trials (n=123) compared CE with MRE. For the suspected CD subgroup, several comparisons met statistical significance. Yields in this subgroup were CE vs. SBR: 52 vs. 16% (IYw=32%, P<0.0001, 95% CI=16-48%), CE vs. CTE: 68 vs. 21% (IYw=47%, P<0.00001, 95% CI=31-63%), and CE vs. C+IL: 47 vs. 25% (IYw=22%, P=0.009, 95% CI=5-39%). Statistically significant yields for CE vs. an alternate diagnostic modality in established CD patients were seen in CE vs. PE: 66 vs. 9% (IYw=57%, P<0.00001, 95% CI=43-71%), CE vs. SBR: 71 vs. 36% (IYw=38%, P<0.00001, 95% CI=22-54%), and in CE vs. CTE: 71 vs. 39% (IYw=32%, P=or<0.0001, 95% CI=16-47%). Our meta-analysis demonstrates that CE is superior to SBR, CTE, and C+IL in the evaluation of suspected CD patients. CE is also a more effective diagnostic tool in established CD patients compared with SBR, CTE, and PE.

ObjectivesColonoscopy is central to colorectal cancer (CRC) screening. Success of CRC screening is dependent on colonoscopy quality. The NHS Bowel Cancer Screening Programme (BCSP) offers biennial faecal occult blood (FOB) testing to 60–74 year olds and colonoscopy to those with positive FOB tests. All colonoscopists in the screening programme are required to meet predetermined standards before starting screening and are subject to ongoing quality assurance. In this study, the authors examine the quality of colonoscopy in the NHS BCSP and describe new and established measures to assess and maintain quality.DesignThe NHS BCSP database collects detailed data on all screening colonoscopies. Prospectively collected data from the first 3 years of the programme (August 2006 to August 2009) were analysed. Colonoscopy quality indicators (adenoma detection rate (ADR), polyp detection rate, colonoscopy withdrawal time, caecal intubation rate, rectal retroversion rate, polyp retrieval rate, mean sedation doses, patient comfort scores, bowel preparation quality and adverse event incidence) were calculated along with measures of total adenoma detection.Results2 269 983 individuals returned FOB tests leading to 36 460 colonoscopies. Mean unadjusted caecal intubation rate was 95.2%, and mean withdrawal time for normal procedures was 9.2 min. The mean ADR per colonoscopist was 46.5%. The mean number of adenomas per procedure (MAP) was 0.91; the mean number of adenomas per positive procedure (MAP+) was 1.94. Perforation occurred after 0.09% of procedures. There were no procedure-related deaths.ConclusionsThe NHS BCSP provides high-quality colonoscopy, as demonstrated by high caecal intubation rate, ADR and comfort scores, and low adverse event rates. Quality is achieved by ensuring BCSP colonoscopists meet a high standard before starting screening and through ongoing quality assurance. Measuring total adenoma detection (MAP and MAP+) as adjuncts to ADR may further enhance quality assurance.

Objective To perform a comprehensive audit of all colonoscopy undertaken in the UK over a 2-week period. Design Multi-centre survey. All adult (≥16 years of age) colonoscopies that took place in participating National Health Service hospitals between 28 February 2011 and 11 March 2011 were included. Results Data on 20 085 colonoscopies and 2681 colonoscopists were collected from 302 units. A validation exercise indicated that data were collected on over 94% of all procedures performed nationally. The unadjusted caecal intubation rate (CIR) was 92.3%. When adjusted for impassable strictures and poor bowel preparation the CIR was 95.8%. The polyp detection rate was 32.1%. The polyp detection rate for larger polyps (≥10mm diameter) was 11.7%. 92.3% of resected polyps were retrieved. 90.2% of procedures achieved acceptable levels of patient comfort. A total of eight perforations and 52 significant haemorrhages were reported. Eight patients underwent surgery as a consequence of a complication. Conclusions This is the first national audit of colonoscopy that has successfully captured the majority of adult colonoscopies performed across an entire nation during a defined time period. The data confirm that there has been a significant improvement in the performance of colonoscopy in the UK since the last study reported seven years ago (CIR 76.9%) and that performance is above the required national standards.