Nervous System Diseases

Symptoms and General Pathology

All Conditions

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Syncope

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Neurologic Manifestations

this groups receives conventional colonoscopy with CO2 withdrawal

This group receives total underwater colonoscopy

one grooup will be randomized to receive a total underwater colonoscopy

Total underwater colonoscopy

one group will be randomized to undergo a conventional colonoscopy with CO2 withdrawal

Conventional colonoscopy

Anna Lisa Schult, MD, PhD

Thomas de Lange, MD, associate prof

Colorectal cancer (CRC), the third most diagnosed cancer and second most common cause of cancer death. CRCs develop from precursors like adenomas (about 70% of CRCs) or serrated lesions (SSLs) (about 25-30% of CRCs). Colonoscopy is the cornerstone in CRC screening, in screening programmes often as a work-up examination after a positive primary screening test such as faecal immunochemical test (FIT). Norway and Sweden have recently launched a nationwide faecal haemoglobin CRC screening programmes. Recently, both a Dutch and an Austrian study showed that SSL detection rate (SSLDR) is inversely correlated to CRC at follow-up. Consequently, improved SSLDR can reduce the risk of post-colonoscopy CRC. SSLs are typically located in the right colon. They are flat, with indistinctive boarders, and consequently easily missed or incompletely resected. A Norwegian study showed incomplete resection of 40% of proximal SSLs. The prevalence of SSLs is higher in women than in men, with women being on a threefold risk of developing CRC from SSLs. It seems like post-colonoscopy CRC more often is caused by SSLs than by adenomas. Total underwater colonoscopy (TUC) is a technique replacing conventional CO2 insufflation by water infusion to distend the lumen and visualise the mucosa during withdrawal of the colonoscope and simultaneously removal of water. There are several reasons to advocate TUC:

1. SSLs will be more visible as they "float" on the submucosa and contract into the lumen, while full distension by gas stretches the mucosa, making detection of flat lesions more difficult.
2. Water works like a magnifying lens, making detection and detailed characterisation of lesions easier.
3. uEMR is eased.
4. Improved bowel cleansing

The goal of this clinical trial is to compare colonoscopy outcomes for standard gas (CO2) insufflation and TUC during withdrawal in patients participating in colonoscopy in the Norwegian and Swedish colorectal cancer screening programme after a positive fecal immunochemical test.

The overarching research questions of the present trial is whether colonoscopy outcomes are improved when CO2 insufflation is replaced by TUC during withdrawal and whether the new technique reduces the ecological footprint of the colonoscopy examination.

The project has five main hypotheses:

1. TUC is superior to the standard approach (CO2 withdrawal) regarding detection of proximal SSLs.
2. TUC increases the rate of complete resection of lesions \&gt;= 10mm.
3. TUC reduces the rate of painful colonoscopies and vasovagal reactions.
4. TUC reduces the health care costs by reduced use of single use accessories and reduced number of redundant colonoscopies to obtain polypfree colon.
5. TUC reduces the carbon footprint by reduced use of single use accessories.

If TUC is superior to gas insufflation, the technique may be implemented rapidly since the technique is easy to learn. This study will increase endoscopy competence at participating centres. The centres are involved in national colonoscopy training programs, so the technique will quickly be passed on to other hospitals and screening centres.

The trial can be linked to three of the Global Goals:

* Good health and well-being: The increased detection and improved complete removal of sessile serrated lesions can subsequently decrease the risk of CRC and CRC mortality during follow-up. TUC will probably reduce the rate of painful procedures and vasovagal reactions and thus increase the acceptance of a screening programme. Consequently, the project can contribute significantly to improve screening effectiveness in Norway and Sweden, particularly in women (women have a higher risk for SSLs and a higher risk of colorectal cancer developing from this type of precursor).
* Gender equality: Women have a similar lifetime risk for CRC as men but less benefit of screening regardless of whether they are screened by sigmoidoscopy, FIT or colonoscopy. The reason is probably missed sessile serrated lesions in the proximal colon. If TUC improves SSLDR and complete lesion resection, this may lead to an equal benefit from CRC screening for women and men. Women have also a higher risk of discomfort and pain during colonoscopy than men. It has been shown that women prefer non-invasive screening modalities, potentially to avoid pain during colonoscopy, even if colonoscopy may be the most beneficial screening method for women. If TUC reduces the rate of painful colonoscopies, it can reduce women's barriers to attend screening.
* Responsible consumption and production: The TUC technique will also reduce the ecological footprint of colonoscopy activity due to reduced consumption of single use accessories and reduced number of colonoscopies to achieve polyp free colon. Furthermore, the cost for the health care system will be substantially reduced.

Total Underwater Colonoscopy (TUC) for Improved Colorectal Cancer Screening: A Randomized Controlled Trial

The proportion of colonoscopies where at least one proximal SSL is detected

water leakage on the way home after colonoscopy

number of single use accesoires per colonoscopy

Ullevaal University Hospital

Sahlgrenska University Hospital, Sweden

Ostfold Hospital Trust

Vestre Viken Hospital Trust

Adenoma

Neoplasms, Glandular and Epithelial

Neoplasms by Histologic Type

Herbal and Botanical

All Drugs and Chemicals

Cola

Cap Assisted Colonoscopy uses a Cap which is a transparent hood which is attached to the distal end of the colonscope and allows depressing the colon folds in order to visualize hidden polyps behind the folds.

A conventional colonoscopy does not use a Cap in order to perform the procedure

Plastic transparent cap added to the distal end of the colonoscope which can increase adenoma detection rate

Cap Assisted Colonoscopy

Regular colonoscopy as per standard clinical guidelines

Mohamed O Othman, MD

This is a research study about the usefulness of transparent cap during screening colonoscopy. The purpose of the research is to test the usefulness of adding small cap to the tip of the colonoscope. the investigators hypothesis is that Cap assisted colonoscopy will improve the detection of adenomatous polyps (polyps which can become colon cancer later on) in comparison to the standard colonoscopy.

This is a prospective, randomized trial comparing the adenoma detection rate between Hispanic patients undergoing a screening colonoscopy with a conventional colonoscope or with a cap-assisted colonoscopy. The aims of the study are:

1. Compare ADR between Hispanic patients undergoing a screening colonoscopy with and without cap.
2. Compare the overall polyp detection rate between Hispanic patients undergoing a screening colonoscopy with and without cap.
3. Compare the cecal intubation rate and cecal intubation time between standard colonoscopy and cap assisted colonoscopy.
4. Compare the complication rate between standard colonoscopy and cap assisted colonoscopy.

The Utility of Cap Colonoscopy in Increasing Adenoma Detection Rate

1. Compare ADR between Hispanic patients undergoing a screening colonoscopy with and without cap.

Texas Tech University Health Sciences Center, El Paso

Principal Investigator

Cap Assisted Colonoscopy uses a Cap which is a transparent hood which is attached to the distal end of the colonscope and allows depressing the colon folds in order to visualize hidden polyps behind the folds.

Cap Assisted Colonoscopy: Plastic transparent cap added to the distal end of the colonoscope which can increase adenoma detection rate

A conventional colonoscopy does not use a Cap in order to perform the procedure

Cap Assisted Colonoscopy: Plastic transparent cap added to the distal end of the colonoscope which can increase adenoma detection rate

Conventional colonoscopy: Regular colonoscopy as per standard clinical guidelines

Conventional Colonoscopy

Total

Age, Categorical

Age, Continuous

Sex: Female, Male

Adenoma Detection Rate

Polyp detection rate

Advanced adenoma detection rate

Mohamed Othman, M.D.

ADR Differences in Hispanic Patients Undergoing a Screening Colonoscopy With and Without Cap.

Overall Study

Patients underwent CCE on day 1 and conventional colonoscopy on day 2

The PillCam® Colon Capsule is 11mm x 31mm in size (Figure 1), is equipped with two cameras acquiring pictures from both ends of the capsule at a rate of 4 frames per second (2 pictures per second and camera). The PillCam® Colon Capsule is automatically activated when it is removed from the package. It enters sleeping mode after approximately 10 minutes and starts transmitting again 1 h 45 min later. It has a total operating time of 8 - 10 hours. During the examination the patient wears a sensor array which is attached to the abdominal skin and a data recorder for storage of the information generated by the ingested capsule. After the examination the data are downloaded into the Given Imaging workstation and a video is generated.

Colon capsule endoscopy

Julia B Pilz, MD

Christoph Beglinger, MD

Lukas Degen, MD

Introduction:

Prevention of colorectal cancer (CRC) is feasible through polypectomy on screening colonoscopy. Patient acceptance remains the main limiting factor for execution. Colon capsule endoscopy (CCE) might be a novel method for large populations.

Aims and methods:

Patients referred for screening means or lower gastrointestinal complaints were included in this single center pilot study. They underwent preparation and then ingested the capsule (PillCam Colon). Standard colonoscopy was performed the next morning. Significance was defined as polyps \>5mm in size. Performance of exams was by independent physician with blinding of results.

Study design This was a prospective, single center pilot analysis under screening conditions. Patient enrollment was from November 5, 2007, to May 7, 2008. All patients provided written informed consent. Patients underwent CCE on day 1 and conventional colonoscopy on day 2, the examinations were done by different physicians. Results were blinded until both examinations had been completed and until interobserver evaluation was finished. Patient acceptance was assessed with a questionnaire after completion of both examinations.

This study was approved by the ethics committee. The study was partly funded by the Nycomed Fund of the University Hospital Basel, Switzerland and by Given Imaging Ltd., Yoqneam, Israel).

The authors designed the study, gathered and analyzed the data; the sponsors had no role in design or conduct of the study nor did they review or approve the data.

Patients Men and women above the age of 50 years without symptoms (Indication for screening) or with lower gastrointestinal signs and symptoms and individuals younger than 50 years, minimum 18 years, without symptoms but with a positive family history for colorectal cancer (CRC) (Indication for screening) were considered for this study. Exclusion criteria were CRC in the patient's history, cardiac pacemaker, contraindications for sodium phosphate solution (Colophos®) and risk factors for capsule retention including surgical intestinal anastomosis, Crohn's disease, diverticulitis and radiologically suspected bowel obstruction.

Data collection General characteristic of the patients were assembled, including demographics, family history and recent surgery, as well as bowel habits.

Hypothesis, Aim and End Points Significance was defined as polyps \>5mm in size, with the hypothesis that detection rate on CCE corresponds with colonoscopy. The aim was to evaluate a novel method (colon capsule endoscopy) for performance as a screening tool compared to conventional colonoscopy in asymptomatic patients. The proclaimed benefit would be an increase in acceptance of screening for colorectal cancer and a probable better detection rate of adenoma resp. carcinoma.

The primary endpoint was the number of cancerous lesions and polyps detected on CCE compared to conventional colonoscopy. Secondary endpoints were completeness of the exam completeness, patient acceptance and adherence to preparation regimen.

Colon preparation and Propulsion of the Capsule For colon cleansing we applied our department's standard preparation procedure for conventional colonoscopy including diet and Macrogolum (PEG, Cololyt®; Spirig Pharma, Egerkingen, Switzerland) and added an oral motility agent, Phospho Soda (Colophos®; Spirig Pharma, Egerkingen, Switzerland)-boosters and a rectal suppository that promotes defecation, Table 1. Patients started with a low residual diet three days prior to the PillCam® Colon examination. The following day they were required to adhere to a liquid diet and one day before the examination to a clear liquid diet. The evening before the examination they ingested 2 litres of Cololyt® between 18:00 and 19:30 and continued with another 2 litres the next morning between 7:00 and 8:30. At 11:00 they were given 2 tablets of Domperidon (Motilium®; Janssen-Cilag AG, Baar, Switzerland) 10mg a couple of minutes prior to the PillCam® Colon capsule. Propulsion from stomach to small bowel was verified using real time viewing before giving the first Colophos® booster (45 ml). That we later abandoned (for the remaining 49 patients) due to satisfactory propulsion. If the capsule had not been excreted by 17:00 (3 hours after the first dose) a second dose of 30 ml Colophos® was added. If it still had not been excreted by 19:30, a suppository of Bisacodylum 10 mg (Prontolax®; Streuli Pharma, Uznach, Switzerland) was administered. The patient removed electrodes and recorder-belt at the excretion of the capsule or at 22:00, which ever came first, and continued clear liquid diet until the conventional colonoscopy was performed the following day.

Pillcam Colon Capsule The PillCam® Colon Capsule is 11mm x 31mm in size (Figure 1). It is equipped with two cameras acquiring pictures from both ends of the capsule at a rate of 4 frames per second (2 pictures per second and camera). Compared to the PillCam® Small Bowel capsule the optic is optimized and more than double of the area coverage and depth view are provided. The PillCam® Colon Capsule is automatically activated when it is removed from the package. It enters sleeping mode in order to save energy after approximately 10 minutes and starts transmitting again 1 h 45 min later. It has a total operating time of 8 - 10 hours. During the examination the patient wears a sensor array which is attached to the abdominal skin and a data recorder for storage of the information generated by the ingested capsule. After the examination the data are downloaded into the Given Imaging workstation and a video is generated.

A New Method for Colorectal Cancer Screening: Colon Capsule Endoscopy Compared to Conventional Endoscopy

University Hospital, Basel, Switzerland

Julia Pilz, Resident, University Hospital Basel

Polyps

It starts from the rectum and progresses forward to the cecum, with observations made during withdrawal: from the cecum, ascending colon, transverse colon, descending colon, and sigmoid colon to the rectum.

After the routine colonoscopy, a repeat colonoscopy of the sigmoid colon is performed

secondary colonoscopy

conventional colonoscopy

Colorectal cancer (CRC) is a malignant tumour originating from the colorectal mucosal epithelium, with rising incidence and mortality rates. Approximately 90% of CRC develops from colorectal polyps, which are considered precancerous lesions of CRC, especially adenomatous polyps. If removed endoscopically during the polyp stage, 70%-90% of CRC can be prevented. However, current colonoscopy examinations have a high miss rate for polyps. Studies have shown that the miss rates for polyps and adenomas after colonoscopy can reach 22%-28% and 12%-26%, respectively.

The "2014 Chinese Guidelines for Early Screening and Endoscopic Diagnosis and Treatment of Colorectal Cancer" mentions that the observation method during colonoscopy starts from the rectum and progresses forward to the cecum, with observations made during withdrawal. However, in actual clinical practice, it is found that single withdrawal observation is not enough, as this examination approach is prone to many missed polyps. The likely reason is that the colon is in a compressed state during withdrawal observation. Single-operator colonoscopy is currently the mainstream insertion method internationally, and the essence of the single-operator technique is "short-axis reductions", meaning that the colonoscope maintains a straight configuration throughout the entire examination. The average adult colon length is about 1.5m, but the distance reached by the colonoscope during the single-operator technique is often between 70-80cm, indicating compression of the colon. In addition, colonic folds become more dense when compressed, making it easier for lesions like polyps to hide within or near folds, leading to misses.

The sigmoid colon, with the most turns in the entire large intestine, is also the part most prone to compression during colonoscopy insertion. Correspondingly, it is also more prone to misses during withdrawal observation. Although some scholars proposed repeating withdrawal to improve lesion detection rates, whether it is performed twice or three times, only compressed colons are observed. In actual clinical work, many polyps can only be found during insertion. The investigators propose performing a second insert specifically for the easily compressed sigmoid colon. During the second insert, the "short-axis reduction" technique should not be used. Instead, the folds should be deliberately advanced into, which helps fully extend the compressed sigmoid colon to shallow or eliminate the folds, allowing observation during advancement to achieve effects beyond multiple withdrawals, finding hidden lesions within or near folds to improve colonoscopy quality. Therefore, to explore whether observing during a second sigmoid colon advancement can further improve the adenoma detection rate to improve colonoscopy quality and reduce interval cancers, the investigators conducted this study.

Colorectal cancer (CRC) is a malignant tumour originating from the colorectal mucosal epithelium, with rising incidence and mortality rates. Currently, CRC ranks third in incidence and second in mortality among all cancers worldwide, making it the leading cancer in terms of global incidence and mortality. Approximately 90% of CRC develops from colorectal polyps, which are considered precancerous lesions of CRC, especially adenomatous polyps. If removed endoscopically during the polyp stage, 70%-90% of CRC can be prevented. However, current colonoscopy examinations have a high miss rate for polyps. Studies have shown that the miss rates for polyps and adenomas after colonoscopy can reach 22%-28% and 12%-26%, respectively.

The "2014 Chinese Guidelines for Early Screening and Endoscopic Diagnosis and Treatment of Colorectal Cancer" mentions that the observation method during colonoscopy starts from the rectum and progresses forward to the cecum, with observations made during withdrawal: from the cecum, ascending colon, transverse colon, descending colon, sigmoid colon to the rectum. Current quality control of colonoscopy mainly focuses on controlling withdrawal time exceeding 6 minutes, controlling cecal intubation rate, and ensuring adenoma detection rate, without specific requirements on the observation method. However, in actual clinical practice, it is found that single withdrawal observation is not enough, as this examination approach is prone to many missed polyps. The likely reason is that the colon is in a compressed state during withdrawal observation. Single-operator colonoscopy is currently the mainstream insertion method internationally, and the essence of the single-operator technique is "short-axis reductions", meaning that the colonoscope maintains a straight configuration throughout the entire examination. The average adult colon length is about 1.5m, but the distance reached by the colonoscope during the single-operator technique is often between 70-80cm, indicating compression of the colon. In addition, colonic folds become more dense when compressed, making it easier for lesions like polyps to hide within or near folds, leading to misses. Currently, in the clinical practice of colonoscopy, only withdrawal observation is performed, and only once, on a compressed colon. Many lesions can be easily missed.

The sigmoid colon, with the most turns in the entire large intestine, is also the part most prone to compression during colonoscopy insertion. Correspondingly, it is also more prone to misses during withdrawal observation. Although some scholars proposed repeating withdrawal to improve lesion detection rates, whether it is performed twice or three times, only compressed colons are observed. In actual clinical work, many polyps can only be found during advancement. The investigators propose performing a second advancement specifically for the easily compressed sigmoid colon. During the second advancement, the "short-axis reduction" technique should not be used. Instead, the folds should be deliberately advanced into, which helps fully extend the compressed sigmoid colon to shallow or eliminate the folds, allowing observation during advancement to achieve effects beyond multiple withdrawals, finding hidden lesions within or near folds to improve colonoscopy quality. Therefore, to explore whether observing during a second sigmoid colon advancement can further improve the adenoma detection rate (ADR) to improve colonoscopy quality and reduce interval cancers, the investigators conducted this study.

The Impact of Repeated Colonoscopic Insert Method on the Detection Rate of Adenomas in the Sigmoid Colon

Number of patients with adenomas detected in the sigmoid colon in each group/number of patients examined in each group

Number of patients with polyps detected in the sigmoid colon in each group/number of patients examined in each group

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Total Underwater Colonoscopy (TUC) for Improved Colorectal Cancer Screening: A Randomized Controlled Trial	NCT06333392	Colorectal Neop... Screening Colon... Colorectal Canc... Colorectal Canc... Vasovagal React...	Total underwate... Conventional co...	55 Years - 60 Years	Vestre Viken Hospital Trust
The Utility of Cap Colonoscopy in Increasing Adenoma Detection Rate	NCT01601431	Adenoma	Cap Assisted Co... Conventional co...	18 Years - 80 Years	Texas Tech University Health Sciences Center, El Paso
Total Underwater Colonoscopy (TUC) for Improved Colorectal Cancer Screening: A Randomized Controlled Trial	NCT06333392	Colorectal Neop... Screening Colon... Colorectal Canc... Colorectal Canc... Vasovagal React...	Total underwate... Conventional co...	55 Years - 60 Years	Vestre Viken Hospital Trust
A New Method for Colorectal Cancer Screening: Colon Capsule Endoscopy Compared to Conventional Endoscopy	NCT00991003	Colorectal Canc...	Colon capsule e... Conventional Co...	18 Years - 85 Years	University Hospital, Basel, Switzerland
The Impact of Repeated Colonoscopic Insert Method on the Detection Rate of Adenomas in the Sigmoid Colon	NCT06186778	Colorectal Poly...	secondary colon... conventional co...	45 Years -	The First Affiliated Hospital of Zhengzhou University

Spots Global Cancer Trial Database for conventional colonoscopy