BACKGROUND Preparation for colon capsule endoscopy (CCE) requires a large liquid laxative volume for capsule excretion, which compromises the procedure's tolerability. AIM To assess the safety and utility of castor oil-boosted bowel preparation. METHODS This prospective cohort study including 20 patients (age range, 16-80 years; six men and 14 women) suspected of having colorectal disease was conducted at Kindai University Hospital from September 2017 to August 2019. All patients underwent CCE because of the following inclusion criteria: previous incomplete colonoscopy in other facility ( n = 20), history of abdominal surgery ( n = 7), or organ abnormalities such as multiple diverticulum ( n = 4) and adhesion after surgery ( n = 6). The exclusion criteria were as follows: Dysphagia, history of allergic reactions to the drugs used in this study (magnesium citrate, polyethylene glycol, metoclopramide, and castor oil), possibility of pregnancy, possibility of bowel obstruction or stenosis based on symptoms, or scheduled magnetic resonance imaging within 2 wk after CCE. The primary outcome was the capsule excretion rate within the battery life, as evaluated by the total large bowel observation rate, large bowel transit time, and bowel creasing level using a five-grade scale in different colorectal segments. The secondary outcomes were complications, colorectal lesion detection rates, and patients’ tolerability. RESULTS The castor oil-based regimen was implemented in 17 patients. Three patients cancelled CCE because they could tolerate castor oil, but not liquid laxatives. The capsule excretion rate within the battery life was 88% (15/17). The mean large bowel transit time was 236 min. Approximately 70% of patients had satisfactory colon cleansing levels. CCE detected colon polyps (14/17, 82%) and colonic diverticulum (4/12, 33%). The sensitivity, specificity, and diagnostic accuracy rates for detecting colorectal polyps (size ≥ 6 mm) were 76.9%, 75.0%, and 76.4%, respectively. The sensitivity, specificity, and diagnostic accuracy rates for detection of diverticulum were 100% each. Twelve patients (71%) rated CCE as more than “good”, confirming the new regimen’s tolerability. No serious adverse events occurred during this study. CONCLUSION The castor oil-based regimen could reduce bowel preparation dose and improve CCE tolerability.
Fig. 1 A 6-mm × 10-cm fully covered braided metal stent with a novel ultra-thin (5.9 Fr; double-headed arrow) delivery system (Benefit; M.I.Tech Co., Ltd., South Korea).Video 1 Novel concept of drainage for malignant hilar biliary obstruction with endoscopic reintervention in mind, with across-the-papilla side-by-side placement of 6-mm fully covered metallic stents.Takenaka Mamoru et al. Across-the-papilla side-by-side placement … Endoscopy |
Endoscopic transpapillary gallbladder drainage (ETGBD) is a drainage method for acute cholecystitis; it is often used in patients who are on antithrombotic drugs or in those presenting with ascites [1-3]. However, the success rate of the procedure is lower than that of percutaneous transhepatic biliary drainage (PTGBD), and one of the reasons for this is the difficulty of inserting the guidewire into the gallbladder [4]. Especially in cases where a stone is impacted in the cystic duct, it becomes even more difficult to insert the guidewire into the gallbladder [5].A 75-year-old man with acute cholecystitis had been referred because of septic shock. The patient was taking two antithrombotic drugs. Computed tomography revealed gallbladder wall thickening, gallstones, and fatstranding around the enlarged gallbladder (▶ Fig. 1). Magnetic resonance cholangiopancreatography confirmed the presence of impacted gallstones in the cystic duct (▶ Fig. 2). Because of the antithrombotic drugs and the presence of ascites, ETGBD was selected as the drainage method. After biliary cannulation, it was not possible to advance a 0.025-inch angled-shape guidewire through the gallstones impacted in the cystic duct and into the gallbladder. Therefore, manipulation using a guidewire that readily forms into a loop shape (J-Wire Prologue; J-MIT, Shiga, Japan) was attempted. This is a 0.025inch guidewire with a soft section as long as 160 mm; the nitinol core is tapered toward the tip, so that it tends to form a loop shape (▶ Fig. 3). This characteristic allowed a loop shape to be easily created, moving the gallstones impacted in the cystic duct to create a gap, so that the guidewire could be passed into the gallbladder (▶ Fig. 4). Finally, an endoscopic nasobiliary drainage tube was successfully placed (▶ Fig. 5; ▶ Video 1), with the cholecystitis improving after drainage. This loop-friendly characteristic is expected to be an effective option in ETGBD for acute cholecystitis with gallstones impacted in the cystic duct.
Video 1 Endoscopic sclerotherapy under balloon-assisted enteroscopy for hemorrhagic jejunal varices after choledocho-jejunostomy. ▶ Fig. 1 Enhanced computed tomography showing jejunal varices (arrow).
Unsuccessful stent replacement in transpapillary biliary drainage with plastic stents (PSs) has a significant impact on patient prognosis; thus, a safe and reliable replacement method is required. We aimed to compare the snare-over-the-guidewire (SOG) method, wherein the PS lumen is used as an access route to the biliary tract and the PS is removed with a snare inserted via the inserted guidewire, with the conventional side-of-stent (SOS) method, wherein the biliary approach is performed from the side of the PS. This retrospective single-center study included 244 consecutive patients who underwent biliary PS replacement between January 2018 and July 2020. The procedural success rates were compared between the two methods. A predictive analysis of unsuccessful PS replacement was also performed. The procedural success rate in the SOG group was significantly higher than that in the SOS group (p = 0.026). In the proximal biliary stenosis lesion, the same trend was observed (p = 0.025). Multivariate analysis also showed that the SOS method (p = 0.0038), the presence of proximal biliary stenosis (p < 0.0001), and parapapillary diverticulum (p = 0.0007) were predictors of unsuccessful PS replacement. The SOG method may be useful for biliary PS replacement, especially in cases of proximal hilar bile duct stenosis.
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