Letters to the editor

and/or need repositioning. In a study of 72 patients undergoing EUS-guided drainage of pseudocysts, the adverse event rate associated with malfunctioning stents was only 1.4%.6 Endoscopic drainage (ED) has been widely adopted as the primary approach for symptomatic pseudocysts because of the high success and the low rates of adverse events when EUS guidance is used.7 Furthermore, the development of novel accessories such as accessotomes,8 which enable 1-step completion of ED without requiring several different types of accessories (eg, dilators, cannulas), will help to reduce the costs of, and time required to complete, ED. Another clear large advantage of ED over PD is the ability to place pancreatic duct stents to treat pancreatic duct disruption, and this represented the basis for 50% of the endoscopic reinterventions in our study.

DISCLOSURE The following author disclosed financial relationships relevant to this publication: V. K. Singh is a consultant for Abbvie Pharmaceuticals, Santarus, D-Pharm, and Boston Scientific. All other authors disclosed no financial relationships relevant to this publication. Venkata S. Akshintala, MD Division of Gastroenterology Atif Zaheer, MD Department of Radiology Vikesh K. Singh, MD, MSc Division of Gastroenterology Johns Hopkins Medical Institutions Baltimore, Maryland, USA

REFERENCES 1. Akshintala VS, Saxena P, Zaheer A, et al. A comparative evaluation of outcomes of endoscopic versus percutaneous drainage for symptomatic pancreatic pseudocysts. Gastrointest Endosc 2014;79:921-8. 2. Adams DB, Harvey TS, Anderson MC. Percutaneous catheter drainage of pancreatic pseudocysts. Am Surg 1991;57:29-33. 3. Mortele KJ, Girshman J, Szejnfeld D, et al. CT-guided percutaneous catheter drainage of acute necrotizing pancreatitis: clinical experience and observations in patients with sterile and infected necrosis. AJR Am J Roentgenol 2009;192:110-6. 4. Zerem E, Imamovic G, Omerovic S, et al. Percutaneous treatment for symptomatic pancreatic pseudocysts: long-term results in a single center. Eur J Intern Med 2010;21:393-7. 5. Andersson B, Nilsson E, Willner J, et al. Treatment and outcome in pancreatic pseudocysts. Scand J Gastroenterol 2006;41:751-6. 6. Varadarajulu S, Christein JD, Wilcox CM. Frequency of complications during EUS-guided drainage of pancreatic fluid collections in 148 consecutive patients. J Gastroenterol Hepatol 2011;26:1504-8. 7. Bergman S, Melvin WS. Operative and nonoperative management of pancreatic pseudocysts. Surg Clin North Am 2007;87:1447-60; ix. 8. Reddy DN, Gupta R, Lakhtakia S, et al. Use of a novel transluminal balloon accessotome in transmural drainage of pancreatic pseudocyst (with video). Gastrointest Endosc 2008;68:362-5. http://dx.doi.org/10.1016/j.gie.2014.01.036


Colon capsule endoscopy after incomplete colonoscopy: Is it really useful and consensual? To the Editor: We were very interested in the article by Triantafyllou et al.1 In their study, Triantafyllou et al investigated the extent that colon capsule endoscopy (CCE) complements incomplete colonoscopy and guides further workup. Although their results are interesting, we believe that some points should be mentioned. First of all, the rate of incomplete colonoscopy is definitely high (10.9%). Even with the patients under conscious sedation/analgesia, it is advisable to achieve a higher cecal intubation.2 To perform an accurate and realistic evaluation of a CCE after incomplete colonoscopy, the authors should consider a population with a higher cecal intubation rate. As mentioned, the CCE visualization of the colon beyond the segment at which colonoscopy stopped was a primary endpoint. However, these data were not strictly collected. The authors did not perform tattooing or clipping at the limit of colonoscopy progression, and so it was difficult to accurately address whether the CCE visualization was satisfactory. This issue should be better described. The willingness to repeat the procedure should also be interpreted with caution. The authors did not state whether the patient knew if any significant finding was found and/or an incomplete CCE was performed; they should perform a third examinationda conventional colonoscopy in most of the cases. Moreover, the need for further workup after a CCE is considered to be very likely (30.7% in the analyzed study). The patient’s knowledge of these issues may decrease the acceptance rate. Last, the follow-up period was not the ideal. Because we were not expecting to have any missed colon cancers on CCE,3 the issue is about missed preneoplastic lesions. The follow-up is probably too short to address the potential harm of the latter. To accurately evaluate this point, a longer follow-up period should be recommended.

DISCLOSURE The authors disclosed no financial relationships relevant to this publication. Carlos Fernandes, MD Rolando Pinho, MD Teresa Pinto Pais, MD Iolanda Ribeiro, MD João Carvalho, MD Department Gastroenterology Centro Hospitalar Vila Nova Gaia Vila Nova Gaia Portugal Volume 79, No. 6 : 2014 GASTROINTESTINAL ENDOSCOPY 1029

Letters to the editor

REFERENCES 1. Triantafyllou K, Viazis N, Tsibouris P, et al. Colon capsule endoscopy is feasible to perform after incomplete colonoscopy and guides further workup in clinical practice. Gastrointest Endosc 2014;79:307-16. 2. Rembacken B, Hassan C, Riemann JF, et al. Quality in screening colonoscopy: position statement of the European Society of Gastrointestinal Endoscopy (ESGE). Endoscopy 2012;44:957-68. 3. Schoofs N, Devière J, Van Gossum A. PillCam colon capsule endoscopy compared with colonoscopy for colorectal tumor diagnosis: a prospective pilot study. Endoscopy 2006;38:971-7. http://dx.doi.org/10.1016/j.gie.2014.01.011

Response We thank our Portuguese colleagues for their interest in our publication.1 We respond to their comments, as follows: 1. The rate of colonoscopy completion in our study population is within the rates reported in clinical practice.2 Moreover, different colon capsule endoscopy (CCE) accuracy is not statistically expected in a population with a higher rate of cecal intubation. The accuracy, usefulness, and consensus of our study results are strongly supported by the literature3 and by the recently presented results of studies on the use of the secondgeneration Given Imaging colon capsule endoscope to complement incomplete colonoscopy.4-6 Irrespective of the population mix of the studies, the CCE complementation rate is 86% to 98%.1,3-6 2. The issue that arises from the lack of marking the site where colonoscopy stopped has been acknowledged and extensively discussed as a study limitation in our publication1 and previously.3 3. The potential need for further workup after CCE was discussed with the study participants during the informed consent procedure. Therefore, our reported procedure acceptance rate is not flawed by this issue. 4. Finally, we cannot disagree that the follow-up period might have been inadequate to allow for the identification of missed preneoplastic lesions. However, our endpoint was focused on the identification of missed cancers.

2. Shah H, Paszat LF, Saskin R, et al. Factors associated with incomplete colonoscopy: a population-based study. Gastroenterology 2007;132: 2297-303. 3. Alarcón-Fernández O, Ramos L, Adrián-de-Ganzo Z, et al. Effects of colon capsule endoscopy on medical decision making in patients with incomplete colonoscopies. Clin Gastroenterol Hepatol 2013;11:534-40. 4. Baltes P, Bota M, Albert J, et al. PillCam Colon2 after incomplete colonoscopy: first preliminary results of a multicenter study. United Eur Gastroenterol J 2013;1(Suppl 1):A190. 5. Spada C, Hassan C, Barbaro B, et al. Colon capsule endoscopy versus colonography in the evaluation of patients with incomplete traditional colonoscopy: a prospective comparative trial. United Eur Gastroenterol J 2013;1(Suppl 1):A126. 6. Nogales O, Lujan M, Nicolas D, et al. Utility of colon capsule endoscopy after an incomplete colonoscopy. Multicentric Spanish study. United Eur Gastroenterol J 2013;1(Suppl 1):A344. http://dx.doi.org/10.1016/j.gie.2014.02.002

The not so NICE classification To the Editor:

1. Triantafyllou K, Viazis N, Tsibouris P, et al. Colon capsule endoscopy is feasible to perform after incomplete colonoscopy and guides further workup in clinical practice. Gasrointest Endosc 2014;79:307-16.

We read with great interest the article by Kumar et al1 in the December issue of GIE in which they retrospectively analyzed the use of Narrow-Band Imaging International Colorectal Endoscopic (NICE) classification by community gastroenterologists for predicting polyp histology. They showed that 37% of sessile serrated adenomas (SSAs) had all 3 features of hyperplastic polyps (HPs), whereas 61% of SSAs had all 3 features of adenomas. They suggested that as many as one third of SSAs could be erroneously classified as innocuous HPs by community gastroenterologists using the NICE classification. The study evaluated a large number of polyps, and the endoscopists evaluating the images were trained in narrow-band imaging and the use of the NICE classification. It highlights the evolving role of optical tools in making management decisions for patients undergoing colonoscopy for colorectal cancer screening. However, we believe that there are several factors that limit the applicability of the study’s conclusions to current standard clinical practice and should be considered before further studies to address similar questions are designed. There are currently no standardized imaging criteria for the identification of sessile serrated adenomas/polyps (SSAs/SSPs). The NICE classification was developed by an international group (Colon Tumor NBI Interest Group), which included Japanese, U.S., French, and U.K. endoscopists. It differentiates colonic lesions based on differences in the color, vessels, and surface pattern without magnifying endoscopy into 3 categories: HPs, adenomas, and submucosally invading carcinomas.2 This study demonstrated the limitations of the NICE classification because it was not developed to differentiate SSAs/SSPs; therefore, there is some overlap of the features found in both HPs and adenomatous polyps. We previously showed that the SSAs/SSPs are difficult to diagnose endoscopically and can be easily

1030 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 6 : 2014


Konstantinos Triantafyllou, MD, PhD Hepatogastroenterology Unit Second Department of Internal Medicine and Research Institute Attikon University General Hospital Medical School, Athens University Athens, Greece


Colon capsule endoscopy after incomplete colonoscopy: Is it really useful and consensual?

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