PRE-PROCEDURE CLEANSE Could colon hydrotherapy improve the quality of colonoscopy screenings?

We caught up with a few of the nation's top gastroenterologists to get their takes on the latest GI trends. They tackled ways to improve adenoma detection rates and the promise of new options in treating gastroesophageal reflux disease (GERD). We lead off, though, with an advance in bowel preps that would eliminate the 2 things patients hate most: fasting and drinking oral preps.

A better bowel prep?
Inadequate bowel preparation is a huge problem, but this sounded too good to be true. Instead of fasting and drinking oral purgatives the night before screenings, colonoscopy patients could undergo a 45-minute warm water colonic irrigation on the day of their colonoscopy exams. When David Johnson, MD, FACG, first heard about this same-day bowel prep alternative, he thought it was a gimmick, but he wanted to find out for himself. The professor of medicine and chief of gastroenterology at the Eastern Virginia School of Medicine in Norfolk hopped an early-morning flight to Austin, Texas, location of the nation's first colon hydrotherapy center, to undergo the cleanse himself. Here's how it works: You're led into a private room and seated on a basin. A sterile disposable nozzle is introduced into your rectum, and a stream of warm water flows into your bowel, loosening stool. Water continues to flow as you evacuate your colon. In less than an hour, you're done.

Dr. Johnson flew back later that day convinced about its game-changing potential for patients who can't tolerate or don't want to endure a liquid bowel prep. Up to 25% of all colonoscopies are reported to have an incomplete standard prep, but Dr. Johnson says patients might not always be at fault for failed preps. "We think it's more involved than that," he says. "The prep selection, prepping instructions as they relate to different languages and cultures, the tools used to navigate around the prep — a host of factors impact prep success."

The company that's launching colon hydrotherapy centers across the country opened one near Dr. Johnson's Norfolk practice (there are 3 others: Austin and Dallas, Texas, and Gilbert, Ariz.). Insurers don't yet cover the service, so his patients must pay $245 out of pocket for the pre-procedure cleanse. Dr. Johnson's group also sends patients with poor preps to the facility in order to salvage that day's colonoscopy, saving the patient and the facility the inconvenience of rescheduling the exam.

"It's a new option for patients who may not otherwise seek colonoscopy over concerns about the prepping process," says Dr. Johnson.

Then there's an edible colon preparation. Instead of downing 2 to 4 liters of a clear liquid prep, patients are given meal kits consisting of bowel-cleansing food infused with a laxative, sorbitol and ascorbic acid.

"The prepackaged meals are intriguing and could offer a nice alternative for colonoscopy prepping for patients who don't react well to liquid cleanse," says Seth Gross, MD, FACG, FASGE, an associate professor of medicine and gastroenterology section chief at NYU Langone Medical Center in New York City. "More studies are needed to ensure it has sustaining power."

Colon cancer screenings
Dr. Johnson helped create the American College of Gastroenterology's consensus colorectal cancer screening guideline, with the ability to exclude polyps at least 6 mm in diameter as the threshold for achieving an adequate colonoscopy exam. He says that threshold is important to promote the discovery of all polyps, particularly flat lesions in the right colon that are more likely to be cancerous. Based on that threshold, roughly three-fourths of colonoscopies are considered adequate, according to Dr. Johnson. "But that's not good enough," he says. "We should set the goal at 85%, and hopefully that goal is surpassed."

There's been a recent push to enhance the detection of adenomas and define colonoscopy quality based on a minimum detection threshold, says Dr. Johnson. He says about one-third of missed incident lesions of colon cancer should have been recognized during a colonoscopy screening.

"Although there have been advancements in imaging and colonoscope maneuvering, none have surpassed what skilled endoscopists can achieve with conventional high-resolution magnification and white light imaging," says Dr. Johnson. "We don't have to wait for future technological advancements to achieve the improvements we're striving for."

Enhanced views of the colon with retrograde imaging or wide views offering an expanded range of visualization have not definitively shown to provide major advantages in terms of outcomes, says Dr. Johnson. "The technology may increase the detection rate of polyps," he explains, "but whether that leads to significant decreases in colon cancer rates is unknown. We have a sizeable potential to make colonoscopy better by making minor improvements made to present-day technology."

Dr. Gross says 360-degree high-def colonoscopes, a reusable clip-on device and flexible endoscope system that provide panoramic views of the colon, and overtubes that improve views of the mucosa and enhance control of the colonoscope's tip all have the potential to improve colonoscopy screenings. But are they worth the added cost? Dr. Gross is currently involved in a study that's comparing these adjuncts with conventional colonoscopy. "Anecdotally they may have value, but truthfully we need objective data based on an extended number of cases to determine if they have staying power," he says. "The add-ons might not be appropriate or accepted by all endoscopists, but perhaps underperforming physicians would benefit the most from enhanced images, larger fields of view or mechanical enhancement of the colonoscope."

Dr. Johnson points to the potential of optical biopsy platforms, which involve the mid-screening resecting and discarding of presumed low-risk polyps based on appearance without having to submit them to pathology. "That would save time and expense," he adds. "Optical biopsy presents an opportunity to decrease the overall cost of colonoscopy and tissue removal."

Getting rid of reflux
Finally, there's a renewed focus on providing patients with relief from the dangerous burn of acid reflux. Adrian Park, MD, chair of the department of surgery at the Anne Arundel Medical Center in Annapolis, Md., says 40 to 60% of the general population experience reflux symptoms. About 10% of those individuals who do not respond to a stepwise approach of dietary and lifestyle modifications require treatment with anti-reflux medications. The 1% who will fail to respond to medical therapy are candidates for interventional therapy, says Dr. Park.

He says there was great interest in endoluminal approaches for the treatment of GERD about 10 to 15 years ago and a flurry of clever products were developed to buttress or embellish the lower esophageal sphincter — the valve between the esophagus and stomach that plays a significant role in the control of reflux. The solutions focused on supporting the function of the lower esophageal sphincter without having to violate the peritoneal cavity. However, none of the solutions provided a safe and durable (more than 6 months) anti-reflux barrier in pathological refluxers, according to Dr. Park. For example, he says, endoscopic radiofrequency ablation impacts reflux scores more than it affects esophageal acid exposure.

Surgeons who opt for endoluminal plication techniques employ an endoscope and proprietary device to reconstruct the angle of His, which is the normally acute angle between the abdominal esophagus and the fundus of the stomach at the esophagogastric junction that's a key component of the body's natural anti-reflux barrier. A growing number of studies authored by champions of the treatment technologies support the efficiency of these approaches, but their market penetrations have so far been lacking, perhaps because physicians remain unconvinced that they provide durable esophageal protection. The endoluminal approaches don't involve laparoscopy or laparotomy, but they're not without risk of various serious complications, says Dr. Park.

He's keeping a close watch on a solution involving the use of magnetic rings implanted laparoscopically to augment the function of the lower esophageal sphincter. The magnetic rings have shown promise in being tolerated after implantation and are distinct from other devices in that they can limit esophageal acid exposure by truly augmenting the function of the natural lower esophageal sphincter. If the rings prove durable and work as designed, they may add to the treatment armamentarium for refractory reflux patients.

Of course, the potential advances in GERD treatments don't stand a chance of becoming mainstream if facilities and surgeons can't get reimbursed for performing them. Dr. Park laments the difficulty he has in getting third-party payers to reimburse for the use of the alternative GERD treatment options and currently relies on laparoscopic Nissen fundoplication to treat his patients. He says the surgery is the current standard of care as long as patients are educated about the lifestyle changes they must make after surgery. "We've learned that it's important to engage and inform patients," he explains. "Lifestyle changes in concert with surgery should solve the condition for the rest of their lives. If they don't agree to those changes, the surgery will be a temporary fix at best." OSM