Cap-assisted Esophagogastroduodenoscopy And Water Exchange Colonoscopy For Detection Of Gastrointestinal Lesions

[Background]Esophagogastroduodenoscopy(EGD)and colonoscopy play an important role on diagnosis and therapy in gastrointestinal diseases.Additional assisted methods could improve the observation and finding of gastrointestinal(GI)lesions.It has been recommended that patients with suspected ampullary diseases should undergo duodenoscopy.Cap-assisted esophagogastroduodenoscopy(CA-EGD)using a transparent cap fitted to the tip of the scope has emerged as an alternative method for examination of the major duodenal papilla(MDP).However,it remains unclear whether CA-EGD is noninferior to standard duodenoscopy for MDP examination Adenoma detection rate(ADR)is an important colonoscopy quality indicator Water-assisted colonoscopy(water exchange[WE]and water immersion[WI])has been shown to improve the adenoma detection rate.However,it remains unclear yet whether the two methods have similar effectiveness on the detection of adenomas Thus,we conducted a network meta-analysis to integrate both direct and indirect evidence comparing the effectiveness of these two procedures[Aims]1.To compare the feasibilities and efficacies of CA-EGD and duodenoscopy for complete examination of the MDP2.To integrate both direct and indirect evidences which compared the effectiveness of WE and WI[Methods]1.This prospective,noninferior,randomized controlled study was conducted at two endoscopy centers.Consecutive patients who underwent endoscopic retrograde cholangiopancreatography were randomized(1:1)to undergo CA-EGD or standard duodenoscopy for MDP examination.The primary outcome was complete examination of the MDP,defined as visualization of the upper end,opening,and lower end of the papilla.Secondary outcomes included endoscopic findings and the time taken for the MDP examination.This study was registered at ClinicalTrials.gov,number NCT032196192.We searched PubMed,Web of Science,and the Cochrane Central Register of Controlled Trials for original papers and abstracts published up to March 2018 Randomized controlled trials(RCTs)reporting data in accordance with the eligibility criteria were included in this study.We performed a Bayesian random effects network meta-analysis with mixed comparisons[Results]1.The study was terminated for futility after the interim analysis.A total of 171 patients were randomly allocated to CA-EGD(n=85)or standard duodenoscopy(n=86).The baseline characteristics were comparable between the two groups Complete examination of the MDP was achieved in 58/85 patients(68.2%)in the CA-EGD group and in 74/86(86.0%)in standard duodenoscopy group.The difference in proportions was-17.81%(95%CI-28.14 to-7.48)by intention-to-treat analysis and-18.22%(95%CI-28.34 to-8.10)by per-protocol analysis,both of which were significantly lower than the noninferiority margin of-5%,and therefore the noninferiority of CA-EGD could not be confirmed.CA-EGD detected more lesions in the upper GI tract overall(62.7%vs.45.2%;P=0.02),esophagus(12.0%vs.1.2%;P=0.005),and stomach(20.5%vs.2.4%;P<0.001).CA-EGD tended to detect more lesions in the duodenal bulb(9.6%vs.2.4%;P=0.23);however,the difference was not significant.Compared with CA-EGD,more lesions were detected in the descending duodenum by standard duodenoscopy(39.3%vs.20.5%;P=0.01).The mean time taken for the examination of the MDP was significantly longer in the CA-EGD group than in the standard duodenoscopy group(69.5s vs.33.Os;P<0.001)The reasons for incomplete examination among 25 patients in the CA-EGD group included periampullary diverticulum(PAD,40%),papilla hidden under folds(36%),abnormal position of the papilla(16%),and swollen papilla(8%).The reasons for incomplete examination among 10 patients in the duodenoscopy group included the presence of PAD(80%)and the papilla hidden under folds(20%)2.Twenty-nine studies(n=11464 patients)including 6 direct and 23 indirect comparisons were included in this network meta-analysis.There was a statistically significant difference in the efficacy of adenoma detection when WE was compared with WI(RR 1.2,95%CrI 1.1-1.3),air insufflation(AI;RR 1.3,95%CrI 1.1-1.4),and carbon dioxide(CO2)insufflation(RR 1.2,95%CrI 1.1-1.5).Compared with WI,WE required a longer caecal intubation time(MD 3.3,95%CrI 1.5-5.1).There were no significant differences in mean pain scores(MD-0.22,95%CrI-1.2 to 0.71),maximum pain scores(MD-0.53,95%CrI 0.95-1.1),willingness to repeat(RR 0.97,95CrI 0.75-1.2),caecal intubation rate(RR 1.0,95%CrI 0.95-1.1),or total procedure time(MD 0.91,95%CrI-0.73 to 2.6)between WE and WI.The different methods were ranked in order from the most to least effective as follows:adenoma detection(WE,WI,AI and CO2),mean/maximum pain scores(AI,C02,WI and WE),willingness to repeat(WE,WI,CO2 and AI),caecal intubation rate(WE,WI,AI and CO2),caecal intubation time(WE,AI,CO2 and WI)and total procedure time(WE,WI,AI and CO2)[Conclusions]1.Although complete examination of the MDP can be achieved by CA-EGD in most patients,it could not replace duodenoscopy as the standard method for examination of the MDP.2.This network meta-analysis supposes that WE may be superior to WI in detecting adenomas during colonoscopies without affecting other technical features or patient acceptance.