Ddw 2011 preliminary program

In a review of water infusion as an adjunct to air insufflation water infusion has been well-documented to facilitate insertion through difficult segments affected by diverticulosis, speed insertion to the cecum and decrease pain. Incremental steps were taken to confirm that cecal intubation could be accomplished using water in lieu of air during insertion in the fully sedated patients 16 , in patients given half the usual doses of sedation medications 16 , in patients given minimal sedation 17 , 18 , in patient offered the option of sedation on-demand 19 , 20 , in sedated patients examined by supervised trainees 18 , 21 , 22 , in patients who underwent scheduled unsedated colonoscopy 23 , 24 , and in patients examined by an experienced colonoscopist who chose self-education and documented the learning curve of the water method 25 , I shall describe the most up-to-date version of the water method as the sole modality for facilitating insertion.

To avoid elongation of the colon by insufflated air, the air pump is turned off. To minimize angulations of the flexures, all residual air in the colon is removed by suction. Water is infused to identify the lumen. To clear the view, water exchange is used. Unlimited water is supplied by the water pump. The residual feces are removed simultaneously by suction to keep the lumen from being excessively distended.

The still images in Figure 1 illustrate the technical details. The tip of the endoscope is pushed against the point where the folds converge. Water is infused to confirm that the lumen lies ahead. Water exchange is used to remove residual feces. With simultaneous infusion of water and suction of residual feces, the turbulence in the vicinity of the tip of the colonoscope dislodges feces from the adjacent mucosa.

Eventually, the lumen clears. Most of the infused water is suctioned out during insertion to obviate excessive distention of the lumen. Examples of the appendix opening under water are shown here. Sometimes, red suction marks indicate arrival in the cecum.

The middle panels reveal one caveat. If air insufflation instead of water exchange is used when difficulty poor view is encountered, identification of the lumen can be made easier.

Water exchange is the preferred approach to deal with a suboptimal bowel preparation in the water method. A suboptimal bowel preparation can be salvaged by the water exchange Fig. The withdrawal phase is done with air insufflation similar to the traditional air method. Still images illustrating the technical details of the water method: a. Most of the dirty water is in the suction bottle during insertion. Water exchange provides salvage cleansing of the colon.

In a RCT comparing air vs. In another RCT, combined with the option of sedation on-demand Fig. The median maximum pain score during colonoscopy was significantly lower in the water group. The water group spent significantly less time in recovery on site and at home.

In the water group, the dose of fentanyl was significantly lower and the lower dose of midazolam approached significance. Outcome of randomized controlled trial in scheduled unsedated patients.

CIR, cecal intubation rate. Outcome of randomized controlled trial in patients examined with the option of on-demand sedation. Sedation medications are means. Significant difference based on Fisher's exact test, Mann-Whitney U test and unpaired t test.

The findings in the above two RCT are being confirmed by several presentations at this meeting. Another RCT from Italy 11 shows that warm water infusion is associated with a decrease in the proportion of patients requesting on-demand sedation as compared to air insufflation and improves patient tolerance and decreases colonoscopy related pain. Another RCT from Germany 30 comparing water infusion vs.

A third observational study during this meeting 33 suggests that application of the water method in community settings in the US is feasible with significantly lower sedation requirement and higher ADR. DR, detection rate. Significant difference based on Fisher's exact test. Head-to-head comparison of adenoma detection rate between water and air methods.

The take home messages are quite clear. Carbon dioxide insufflation decreases pain after colonoscopy. To put the new knowledge presented this afternoon into planning the next study, I propose the following. The study method is a combination of the water method without air or CO 2 insufflation for insertion and CO 2 insufflation for withdrawal. The study method will be compared with any traditional techniques or new methods.

Data will include pain during and after colonoscopy; and lesion yield both adenomas and sessile serrated polyps. If the data discussed this afternoon can be reproduced, the combination will decrease pain, provide salvage cleansing and increase proximal lesion yield. My speculations are as follows Fig. This combination may lead to the possibility of decreased sedation, less assistant help, improved bowel preparation and decreased missed lesions. Decreased sedation may result in less time spent in recovery, less need for escort if scheduled unsedated colonoscopy is progressively more successful.

Overall patient burden escort requirement and recovery time spent on site and for home recovery can be minimized. Activation of the BMP4 pathway and early expression of CDX2 characterize the development of nonspecialized columnar metaplasia in a human model of Barrett esophagus. Esophageal squamous cell lines derived from GERD patients with and without Barrett's esophagus differ markedly in their expression of SOX9 and columnar cytokeratins 8 and Combinatorial chemoprevention reveals a novel smoothened independent role of GLI1 in esophageal carcinogenesis.

Deregulated Hedgehog signaling in the pathogenesis of Barrett's disease and gastric adenocarcinoma. Beneficial effect of exogenous and endogenous melatonin in the experimental model of Barrett's esophagus in rats. Quantitative variability of molecular biomarkers in Barrett's esophagus. Aberrant gene methylation in the neoplastic progression of Barrett's esophagus: identification of candidate diagnostic markers.

Investigation for biomarkers of Barrett's esophagus. Relationship between Barrett's esophagus BE length and the risk of high grade dysplasia HGD and esophageal adenocarcinoma EAC in patients with non dysplastic Barrett's esophagus results from a large multicenter cohort. Barrett's Dysplasia Cancer Task Force — Bad Cat: a global, multidisciplinary, consensus on the management of high grade dysplasia and early mucosal cancer in Barrett's esophagus.

Endoscopic resection in patients with mucosal Barrett's cancer. Effective acid suppression is important in squamous reepithelialization after radiofrequency ablation of Barrett's esophagus. Endoscopic submucosal dissection for Barrett's high grade dysplasia or early adenocarcinoma: a U. Outcomes of esophagogastric junction adenocarcinomas initially treated by endoscopic resection.

VEGF signaling exerts pronounced effects on cell growth in transformed Barrett's epithelial cells. Overview of the cohort consortium vitamin D pooling project of rarer cancers. Vitamin D, calcium and dairy intake, and risk of oesophageal adenocarcinoma and its precursor conditions.

MicroRNAs in Barrett's esophagus and esophageal adenocarcinoma. Comparative evaluation of novel putative stem cell markers and tumor suppressor microRNAs in Barrett's esophagus. Statins inhibit proliferation and induce apoptosis in Barrett's esophageal adenocarcinoma cells. Medications NSAIDs, statins, proton pump inhibitors and the risk of esophageal adenocarcinoma in patients with Barrett's esophagus. Genomic medicine — a primer. Read and print from thousands of top scholarly journals.

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