AIMTo assess the utility of modified Sano′s (MS) vs the narrow band imaging international colorectal endoscopic (NICE) classification in differentiating colorectal polyps.METHODSPatients undergoing colonoscopy between 2013 and 2015 were enrolled in this trial. Based on the MS or the NICE classifications, patients were randomised for real-time endoscopic diagnosis. This was followed by biopsies, endoscopic or surgical resection. The endoscopic diagnosis was then compared to the final (blinded) histopathology. The primary endpoint was the sensitivity (Sn), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of differentiating neoplastic and non-neoplastic polyps (MS II/IIo / IIIa / IIIb vs I or NICE 1 vs 2/3). The secondary endpoints were “endoscopic resectability” (MS II/IIo/IIIa vs I/IIIb or NICE 2 vs 1/3), NPV for diminutive distal adenomas and prediction of post-polypectomy surveillance intervals.RESULTSA total of 348 patients were evaluated. The Sn, Sp, PPV and NPV in differentiating neoplastic polyps from non-neoplastic polyps were, 98.9%, 85.7%, 98.2% and 90.9% for MS; and 99.1%, 57.7%, 95.4% and 88.2% for NICE, respectively. The area under the receiver operating characteristic curve (AUC) for MS was 0.92 (95%CI: 0.86-0.98); and AUC for NICE was 0.78 (95%CI: 0.69, 0.88). The Sn, Sp, PPV and NPV in predicting “endoscopic resectability” were 98.9%, 86.1%, 97.8% and 92.5% for MS; and 98.6%, 66.7%, 94.7% and 88.9% for NICE, respectively. The AUC for MS was 0.92 (95%CI: 0.87-0.98); and the AUC for NICE was 0.83 (95%CI: 0.75-0.90). The AUC values were statistically different for both comparisons (P = 0.0165 and P = 0.0420, respectively). The accuracy for diagnosis of sessile serrated adenoma/polyp (SSA/P) with high confidence utilizing MS classification was 93.2%. The differentiation of SSA/P from other lesions achieved Sp, Sn, PPV and NPV of 87.2%, 91.5%, 89.6% and 98.6%, respectively. The NPV for predicting adenomas in diminutive rectosigmoid polyps (n = 150) was 96.6% and 95% with MS and NICE respectively. The calculated accuracy of post-polypectomy surveillance for MS group was 98.2% (167 out of 170) and for NICE group was 92.1% (139 out of 151).CONCLUSIONThe MS classification outperformed the NICE classification in differentiating neoplastic polyps and predicting endoscopic resectability. Both classifications met ASGE PIVI thresholds.

AIMTo compare high definition white light endoscopy and bright narrow band imaging for colon polyps’ detection rates.METHODSPatients were randomised to high definition white light endoscopy (HD-WLE) or the bright narrow band imaging (bNBI) during withdrawal of the colonoscope. Polyps identified in either mode were characterised using bNBI with dual focus (bNBI-DF) according to the Sano’s classification. The primary outcome was to compare adenoma detection rates (ADRs) between the two arms. The secondary outcome was to assess the negative predictive value (NPV) in differentiating adenomas from hyperplastic polyps for diminutive rectosigmoid lesions.RESULTSA total of 1006 patients were randomised to HD-WLE (n = 511) or bNBI (n = 495). The mean of adenoma per patient was 1.62 and 1.84, respectively. The ADRs in bNBI and HD-WLE group were 37.4% and 39.3%, respectively. When adjusted for withdrawal time (OR = 1.19, 95%CI: 1.15-1.24, P < 0.001), the use of bNBI was associated with a reduced ADR (OR = 0.69, 95%CI: 0.52-0.92). Nine hundred and thirty three polyps (86%) in both arms were predicted with high confidence. The sensitivity (Sn), specificity (Sp), positive predictive value and NPV in differentiating adenomatous from non-adenomatous polyps of all sizes were 95.9%, 87.2%, 94.0% and 91.1% respectively. The NPV in differentiating an adenoma from hyperplastic polyp using bNBI-DF for diminutive rectal polyps was 91.0%.CONCLUSIONADRs did not differ between bNBI and HD-WLE, however HD-WLE had higher ADR after adjustment of withdrawal time. bNBI surpassed the PIVI threshold for diminutive polyps.

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Background: Carbon dioxide (CO 2 ) insufflation has been shown to reduce post-procedural pain in endoscopic procedures such as flexible sigmoidoscopy and colonoscopy due to improved absorption via the gastrointestinal tract and subsequent reduction in bowel distension. The benefit of CO 2 insufflation in upper endoscopic procedures including endoscopic retrograde cholangiopancreatography (ERCP) is less clear.Aim: To evaluate the efficacy and safety of carbon dioxide insufflation in ERCP. Methods:We conducted a prospective randomised controlled trial of patients requiring ERCP at Lyell McEwin Hospital (Adelaide, Australia) between 2011 and 2013. Patients were randomised to air insufflation or CO 2 . Post-procedural pain, abdominal distension, nausea, capnography and adverse events were recorded on arrival to the recovery room, 1 hour post-recovery, on discharge and 24 hours postdischarge. Baseline characteristics of each study group were compared with Student's t tests for quantitative variables and a chi-squared test for qualitative variables. Results were deemed statistically significant when the P value was <0.05. Results:A total of 94 patients were randomised in this trial. There were no significant differences in abdominal distension, nausea, capnography, amount of sedation used and adverse events noted at any time point after ERCP was performed.Patients in the air group experienced significantly more abdominal pain in comparison to the CO 2 arm (2.0 vs 0.9; P = 0.027) 1 hour after the procedure. No significant difference in post-procedural pain was noted at the other time points.Conclusion: Although safe to use in ERCP, CO 2 insufflation appears to have little to no benefit over standard air insufflation alone.