USE OF CAP ATTACHED TO THE FORWARD-VIEWING ENDOSCOPE INCREASES THE AMPULLA OF VATER VISUALIZATION IN HIGH RISK PATIENTS

Complete visualization of ampulla of Vater (AV) in patients at risk of periampullary neoplasia requires a duodenoscope availability and expertise for its handling. Recently, the use of Cap attached to the forward-viewing endoscope has been described as an alternative, but there is limited data in the literature regarding its efficacy in patients with indication AV’s visualization. Objectives: The primary aim was to compare the rates of AV’s complete visualization between forward-viewing endoscopy (FVE) and Cap-assisted endoscopy (CAE). Secondary, we intended to determine the rates of complications and additional sedation for CAE, as well as to compare the mean time of duodenal examination between FVE and CAE and to estimate the reproducibility among the endoscopists. Prospective study, including 80 consecutive patients >18 years old with indication of complete AV visualization. All patients underwent FVE followed by CAE, performed by residents supervised by expert endoscopists. Duodenal second portion videos were randomly evaluated by two other experts endoscopists, blindly for identification. Patient mean age was 40.79 years (± 17.12) and 63.7% female. The AV indications were: familial adenomatous polyposis (86.2%), pancreatic and AV neoplasia (5% and 8.8%). AV complete visualization rate was higher in CAE (96.2 %) compared to FVE (48.8%) (p<0.001). Additional doses of fentanyl, midazolan and propofol for CAE were 0.05, 1.91 and 37.26 mg. in 1.5, 25 and 77.5% patients, respectively. Mean time of duodenal examination was lower on CAE vs. FVE (1.45 vs. 2.13 min, p<0.001). Scopolamine was used in 27 FVE and 16 CAE, with no association to AV complete visualization rates (p=0.24 and p=0.11). Two extra ampullary adenomas were found on CAE. Cap displacement was reported in one patient and any adverse effect of the additional sedatives used was observed. Interobserver agreement was moderate to excellent (kappa 0.55-0.80). Cap-assisted endoscopy is feasible and safe, with higher success for complete visualization of AV, compared to forward-viewing endoscopy. Finally, the reproducibility between endoscopists was moderate to excellent.