COLON: Innovations 3 steps, 3 parts..

COLON: Innovations 3 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

Detection: : innovations..2 different approaches IMAGE QUALITY TOLERANCE to improve the pt compliance to screening (mass screening or individual screening)

How to improve patient tolerance?

New colonoscopes = mechanical part of the endoscope has been modified to facilitate insertion (and visualization) 1- Aer-O-scope 2- Colonosight 3- Invendo 4- Ethicon 5- Neoguide 6- Shapelock 7- Spiral overtube 8- Videocapsule

Is it possible to classify them? We must take into account the mass screening process: How is mass screening organized?

Mass screening of CRC = 2 tests first test: FOBT, second test: colonoscopy if first test positive

Some could replace the first test Ethicon Aer-O-scope Capsule because they have no therapeutic capabilities (no operating channel) Some could replace the second test: Invendo Neoguide Colonosight Overtube: Shapelock Spiral overtube

Abandoned

Vucelic Gastroenterology 2006: 10 caecal intubations /12

Almost abandoned

European study 320 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%

Pneumatic bending Remote control LED Operating channel Rösch GIE 2008 34 patients 82% caecal intubation Single-use colonoscope

Pneumatic bending Remote control Uncertain future LED Operating channel Single-use colonoscope

NeoGuide Endoscopy System Eickhoff Am J Gastro 2007 10 caecal intubations / 11 Abandoned Development for «NOTES»

Pneumatic propeller LED Single use sheath

Almost Abandoned Only focused on single use sheath

Improving pt tolerance new colonoscopes: Conclusion Very disappointing Capsule: almost the last product Main problem with capsule = bowel cleansing

Detection: : innovations..2 different approaches IMAGE QUALITY TOLERANCE to improve the pt compliance to screening (mass screening or individual screening)

IMAGE QUALITY : innovations Virtual chromoscopy Autofluorescence Image enlargement

Narrow band imaging Spectrum White light NBI

Adenoma Detection Adenoma detection - Randomised % with 1+ adenomas 80 70 60 50 40 30 20 10 0 65 67 23 17 72 60 51 44 NBI White Light Rex Adler East Kaltenbach Rex D et al GIE 2006 Adler A et al. Gut 08 East JE et al. DDW 07 Kaltenbach TR et al. DDW 07 Inoue T J Gastro 2008: 243 pts, No effect

HNPCC Adenoma detection - proximal colon At least one adenoma 45% 40% 35% 30% 25% 20% 15% 10% 5% 27% WL 42% NBI P=.004 White light WL + NBI 0% Proportion flat adenomas Proportion flat adenomas 50% 40% 30% 20% 10% 3/25 12% 45% 9/21 NBI White light NBI P=.03 East JE et al. Gut 08 0%

Detection DALMs in Colitis NBI can detect and characterise DALMs Not better than white light East et al. Gut 2006;55:1432-35 35 Dekker et al. Endoscopy 2007;39:216-21 21

NBI: detection Average risk population Is virtual chromoendoscopy recommended as the standard for CCR screening? No. High risk population: HNPCC Can NBI replace chromoendoscopy? Possibly Yes High risk population: UC surveillance Can 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

IMAGE QUALITY : innovations Virtual chromoscopy Autofluorescence Image enlargement

Autofluorescence Colon AFI Juntendo University AFI

Matsuda Am J Gastroenterol 167 pts, random AFI vs WL + 34% adenomas However Some disappointements

IMAGE QUALITY : innovations Virtual chromoscopy Autofluorescence Image enlargement = To better see behind the folds

Wide angle colonoscope 210 standard 140 Rex Am J Gastro 2003 Deenadayalu Am J Gastro 2004 Pb = 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: Conclusion NBI and FICE: limited role Autofluorescence: uncertain Image enlargement: interesting field but japanese companies not so interested Why?

COLON: Innovations Detection Characterization Treatment

Can we replace biopsies? Can we let in place a polyp? Can we orientate the management (IBD?)

CHARACTERIZATION : innovations Virtual chromoscopy Endocystoscopy Confocal microscopy

NBI: pit pattern (such as for chromoscopy) Hyperplastic Adenoma Carcinoma Hirata, GIE 2007

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

NBI: vascular pattern Hyperplastic Weak vascular pattern Adenoma: strong vascular pattern

NBI: Adenoma vs hyperplastic polyp? Polyp number Sensitivity Specificity Chiu Gut 2007* 180 87-95 % 72-88 % Su Am J Gastro 2006* 110 96 88 Hirata GIE 2007 100 99 94 Machida Endoscopy 2004 43 100 75 East GIE 2007 33 77-91 50-60 Tischendorf Endosc 2007 200 90-94 89-89

From all these data concerning NBI, If we say type II = hyperplastic polyp, we have 6% of risk that the polyp is adenomatous If we say type III = adenomatous polyp, we have 16% of risk that the polyp is hyperplastic

chromoendo NBI Risk to miss adenoma 13% 6% Risk to miss hyperplastic. 25% 16%

CHARACTERIZATION : innovations Virtual chromoscopy Endocystoscopy Confocal microscopy

Confocal microscopy Light Guide Light Guide CCD Confocal Imaging Window Air/Water Nozzles Biopsy Channel Auxiliary Water Jet Channel

Ileum Kiesslich

Hyperplasia Kiesslich

Adenoma Kiesslich

Colonic cancer Kiesslich

Cancer in-situ Kiesslich

Mild UC Kiesslich

Severe UC Kiesslich

Kiesslich Gastroenterol 2007 Diagnosis of neoplastic changes on IBD Accuracy = 97.8% 10 fold reduction of the number of biopsies Hurstone 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: Conclusion NBI : promising to characterize polyps but is it helpful? (ex: serrated adenomas) Endomicroscopy: to be evaluated Confocal microscopy: Very effective in IBD in expert hands But needs confirmation in routine

COLON: Innovations Detection Characterization Treatment

Last advance = Endoscopic submucosal dissection (ESD)

IT knife Needle knife Flex knife Hook knife

Results of Colorectal ESD En bloc resection 97.7% (209/214) Curative resection 89.7% (192/214) Perforation 7.0% (15/214) Delayed Perforation 0.9% (2/214): surg Delayed bleeding 3.7% (8/214) Local recurrence 0% (0/214) Apr. 2005-Jan.2008, Toranomon Hospital

RESULTS OF ESD Nbr en-bloc R0 Perf CR TANAKA 70 80% 10% 100% GIE 07 FUJISHIRO 35 88% 63% 6% 100% GIE 06 TAMAGAI 105 99% 1% UEGW07 Lyon 16 75% 44% 12%

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

Main advantage of ESD = resection is aiming R0

Adenoma Aiming R0 Not aiming R0

Adenoma Aiming R0 Fragments = piece-meal Not aiming R0

piece-meal

Which are the 2 consequences to do not get a R0 resection? 1- Risk of «recurrence» = 30% Rate increased with diameter with 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 risk Procedure 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

Invasive car Adenoma Fragments

Invasive car Adenoma

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

2 CLASSIFICATIONS to be known Paris classification macroscopy, general pattern Kudo classification macroscopy, pitt pattern

Polypoïd 0-Ip pedunculated 0-Is sessile Flat 0-IIa 0-IIb 0-IIc surelevated flat depressed 0-III Ulcerated

Complex patterns IIc + IIa IIa + IIc LST = Is + IIc

II a + II c II c + II a

Submucosal invasion 120 100 80 60 40 Oeso Stomach Colon 20 0 0-I 0-II a 0-II b 0-II c III

2 CLASSIFICATIONS to be known Paris classification macroscopy, general pattern Kudo classification macroscopy, pitt pattern

Small tubular large tubular branched IIIS adenoma IIIL IV

irregular Non structured VI carcinoma VN

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

0-III Ulcerated Reference = surgery Endoscopy only if aiming R0

0-IIc If Kudo type V Reference = surgery Endoscopy only if aiming R0 IIc + IIa IIa + IIc LST = Is + IIc

II a + II c II c + II a

Treatment: conclusion on ESD Adenoma = cost-effectiveness analyzis is required Suspicion 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 innovations Different aims: needs to be classified (detection, characterization) Frequently disappointing Will not replace good practice (ex: adenoma detection rate, biopsies, EMR)