Irrigating Acetic Acid Solution During Colonoscopy for the Detection of Sessile Serrated Neoplasia: A Randomized Controlled Trial

Abstract

Background

Misdiagnosed sessile serrated lesions (SSLs) are important precursors for interval colorectal cancers.

Aims

We investigated the usage of acetic acid (AA) solution for improving the detection of SSLs in the right colon in a randomized controlled trial.

Methods

A tandem observation of the right colon was performed in 412 consecutive patients. A first inspection was performed under white light high-definition endoscopy. In the AA group, a low concentration vinegar solution (AA: 0.005%) irrigated by a water pump in the right colon was compared with a plain solution of normal saline (NS) in the diagnostic yield of SSLs during the second inspection. Secondary outcomes in overall polyp detection were measured.

Results

Qualitative comparisons showed significant differences in the detection rates of all polyps except adenomas, with remarkable improvement in the demonstration of advanced (> 20 mm), SSLs, and hyperplastic polyps during the second inspection of the right colon using the AA solution. Significant improvement was also noted in the AA group, as far as the mean number of polyps/patient detected, not only in SSLs (AA group: 0.14 vs. NS group: 0.01, P < 0.001), but also in all histological types and all size-categories in the right colon. Small (≤ 9 mm) polyps were detected at a higher rate in the sigmoid colon expanding the effect of the method in the rest of the colon.

Conclusion

AA-assisted colonoscopy led to a significant increase in SSLs detection rate in the right colon in a safe, quick, and effective manner.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3

References

  1. 1.

    Johnston CS, Gaas CA. Vinegar: medicinal uses and antiglycemic effect. MedGenMed. 2006; 8(2): 61. Published 2006 May 30.

  2. 2.

    Jung HH, Cho SD, Yoo CK, Lim HH, Chae SW. Vinegar treatment in the management of granular myringitis. J Laryngol Otol. 2002;116:176–180. https://doi.org/10.1258/0022215021910474.

    Article  PubMed  Google Scholar 

  3. 3.

    Aminifarshidmehr N. The management of chronic suppurative otitis media with acid media solution. Am J Otol. 1996;17:24–25

    CAS  PubMed  Google Scholar 

  4. 4.

    Santesso N, Mustafa RA, Schünemann HJ et al. World Health Organization Guidelines for treatment of cervical intraepithelial neoplasia 2–3 and screen-and-treat strategies to prevent cervical cancer. Int J Gynaecol Obstet. 2016;132:252–258. https://doi.org/10.1016/j.ijgo.2015.07.038.

    Article  PubMed  Google Scholar 

  5. 5.

    Lambert R, Rey JF, Sankaranarayanan R. Magnification and chromoscopy with the acetic acid test. Endoscopy. 2003;35:437–445. https://doi.org/10.1055/s-2003-38766.

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Yagi K, Aruga Y, Nakamura A, Sekine A, Umezu H. The study of dynamic chemical magnifying endoscopy in gastric neoplasia. Gastrointest Endosc. 2005;62:963–969. https://doi.org/10.1016/j.gie.2005.08.050.

    Article  PubMed  Google Scholar 

  7. 7.

    Parra-Blanco A, Fu KI, Nicolás-Pérez D, Gimeno-García AZ, Carrillo M, Quintero E. Is acetic acid really effective as a mucolytic agent for magnifying colonoscopy diagnosis? Endoscopy. 2007;39:920–923. https://doi.org/10.1055/s-2007-966846.

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Kim JH, Lee SY, Kim BK et al. Importance of the surrounding colonic mucosa in distinguishing between hyperplastic and adenomatous polyps during acetic acid chromoendoscopy. World J Gastroenterol. 2008;14:1903–1907. https://doi.org/10.3748/wjg.14.1903.

    Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Zimmer V, Heinrich C, Lammert F. Open pit pattern identifies sessile serrated adenoma/polyp on non-magnified acetic acid-enhanced colonoscopy. Clin Res Hepatol Gastroenterol. 2020;44:119–120. https://doi.org/10.1016/j.clinre.2019.04.006.

    Article  PubMed  Google Scholar 

  10. 10.

    Shibagaki K, Amano Y, Ishimura N et al. Magnification endoscopy with acetic acid enhancement and a narrow-band imaging system for pit pattern diagnosis of colorectal neoplasms. J Clin Gastroenterol. 2015;49:306–312. https://doi.org/10.1097/MCG.0000000000000148.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Togashi K, Hewett DG, Whitaker DA, Hume GE, Francis L, Appleyard MN. The use of acetic acid in magnification chromocolonoscopy for pit pattern analysis of small polyps. Endoscopy. 2006;38:613–616. https://doi.org/10.1055/s-2006-925001.

    CAS  Article  PubMed  Google Scholar 

  12. 12.

    Goto N, Kusaka T, Tomita Y et al. Magnifying narrow-band imaging with acetic acid to diagnose early colorectal cancer. World J Gastroenterol. 2014;20:16306–16310. https://doi.org/10.3748/wjg.v20.i43.16306.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Wiessner JR, Brown H, Haller B et al. Near focus NBI endoscopy plus acetic acid for optical polyp characterization in the colorectum - A proof of principle study. Scand J Gastroenterol. 2019;54:377–383. https://doi.org/10.1080/00365521.2019.1588364.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Onishi K, Kono Y, Higashi R. Acetic Acid Spray With Narrow-Band Imaging Is Useful to Clarify the Margin of Sessile Serrated Adenoma/Polyp [published online ahead of print, 2019 Nov 11]. Am J Gastroenterol. 2019; https://doi.org/10.14309/ajg.0000000000000447.

  15. 15.

    Fujimoto D, Muguruma N, Okamoto K et al. Linked color imaging enhances endoscopic detection of sessile serrated adenoma/polyps. Endosc Int Open. 2018;6:E322–E334. https://doi.org/10.1055/s-0043-124469.

    Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Yoshida N, Dohi O, Inoue K et al. The efficacy of tumor characterization and tumor detectability of linked color imaging and blue laser imaging with an LED endoscope compared to a LASER endoscope. Int J Colorectal Dis. 2020;35:815–825. https://doi.org/10.1007/s00384-020-03532-y.

    Article  PubMed  Google Scholar 

  17. 17.

    Yamamoto S, Shafazand M. Acetic acid-indigocarmine mixture for evaluating the margins of sessile serrated adenomas/polyps. Dig Endosc. 2017;29:817–818. https://doi.org/10.1111/den.12947.

    Article  PubMed  Google Scholar 

  18. 18.

    Limketkai BN, Lam-Himlin D, Arnold MA, Arnold CA. The cutting edge of serrated polyps: a practical guide to approaching and managing serrated colon polyps [published correction appears in Gastrointest Endosc: 2014 Mar; 79(3):542]. Gastrointest Endosc. 2013;77:360–375. https://doi.org/10.1016/j.gie.2012.11.013.

    Article  PubMed  Google Scholar 

  19. 19.

    Tribonias G, Theodoropoulou A, Konstantinidis K, et al. Comparison of standard vs high-definition, wide-angle colonoscopy for polyp detection: a randomized controlled trial. Colorectal Dis. 2010; 12(10 Online): e260–e266. https://doi.org/10.1111/j.1463-1318.2009.02145.x

  20. 20.

    Kastenberg D, Bertiger G, Brogadir S. Bowel preparation quality scales for colonoscopy. World J Gastroenterol. 2018;24:2833–2843. https://doi.org/10.3748/wjg.v24.i26.2833.

    Article  PubMed  PubMed Central  Google Scholar 

  21. 21.

    Papastergiou V, Paraskeva KD, Fragaki M et al. Cold versus hot endoscopic mucosal resection for nonpedunculated colorectal polyps sized 6–10 mm: a randomized trial. Endoscopy. 2018;50:403–411. https://doi.org/10.1055/s-0043-118594.

    Article  PubMed  Google Scholar 

  22. 22.

    Tate DJ, Awadie H, Bahin FF et al. Wide-field piecemeal cold snare polypectomy of large sessile serrated polyps without a submucosal injection is safe. Endoscopy. 2018;50:248–252. https://doi.org/10.1055/s-0043-121219.

    Article  PubMed  Google Scholar 

  23. 23.

    Tutticci NJ, Hewett DG. Cold EMR of large sessile serrated polyps at colonoscopy (with video). Gastrointest Endosc. 2018;87:837–842. https://doi.org/10.1016/j.gie.2017.11.002.

    Article  PubMed  Google Scholar 

  24. 24.

    Crockett SD, Gourevitch RA, Morris M et al. Endoscopist factors that influence serrated polyp detection: a multicenter study. Endoscopy. 2018;50:984–992. https://doi.org/10.1055/a-0597-1740.

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Fan C, Younis A, Bookhout CE, Crockett SD. Management of Serrated Polyps of the Colon. Curr Treat Options Gastroenterol. 2018;16:182–202. https://doi.org/10.1007/s11938-018-0176-0.

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Okamoto K, Kitamura S, Kimura T et al. Clinicopathological characteristics of serrated polyps as precursors to colorectal cancer: Current status and management. J Gastroenterol Hepatol. 2017;32:358–367. https://doi.org/10.1111/jgh.13482.

    Article  PubMed  Google Scholar 

  27. 27.

    Crockett SD, Nagtegaal ID. Terminology, Molecular Features, Epidemiology, and Management of Serrated Colorectal Neoplasia. Gastroenterology. 2019;157:949-966.e4. https://doi.org/10.1053/j.gastro.2019.06.041.

    Article  PubMed  Google Scholar 

  28. 28.

    Bettington M, Walker N, Rahman T et al. High prevalence of sessile serrated adenomas in contemporary outpatient colonoscopy practice. Intern Med J. 2017;47:318–323. https://doi.org/10.1111/imj.13329.

    Article  PubMed  Google Scholar 

  29. 29.

    Rex DK, Clodfelter R, Rahmani F et al. Narrow-band imaging versus white light for the detection of proximal colon serrated lesions: a randomized, controlled trial. Gastrointest Endosc. 2016;83:166–171. https://doi.org/10.1016/j.gie.2015.03.1915.

    Article  PubMed  Google Scholar 

  30. 30.

    Desai M, Sanchez-Yague A, Choudhary A et al. Impact of cap-assisted colonoscopy on detection of proximal colon adenomas: systematic review and meta-analysis. Gastrointest Endosc. 2017;86:274-281.e3. https://doi.org/10.1016/j.gie.2017.03.1524.

    Article  PubMed  Google Scholar 

  31. 31.

    Van Keulen KE, Soons E, Siersema PD. The Role of Behind Folds Visualizing Techniques and Technologies in Improving Adenoma Detection Rate. Curr Treat Options Gastroenterol. 2019;17:394–407. https://doi.org/10.1007/s11938-019-00242-5.

    Article  PubMed  Google Scholar 

  32. 32.

    Okabe S, Okamoto T, Zhao CM, Chen D, Matsui H. Acetic acid induces cell death: an in vitro study using normal rat gastric mucosal cell line and rat and human gastric cancer and mesothelioma cell lines. J Gastroenterol Hepatol. 2014;29:65–69. https://doi.org/10.1111/jgh.12775.

    CAS  Article  PubMed  Google Scholar 

  33. 33.

    Kashida H. Endoscopic diagnosis of sessile serrated polyp: A systematic review. Dig Endosc. 2019;31:16–23. https://doi.org/10.1111/den.13263. Epub 2018 Sep 30. PMID: 30151942; PMCID: PMC7379725.

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to George Tribonias.

Ethics declarations

Conflict of interest

The authors declare that there is no conflict of interest.

Ethical approval

All procedures performed in the study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Tribonias, G., Theodoropoulou, A., Stylianou, K. et al. Irrigating Acetic Acid Solution During Colonoscopy for the Detection of Sessile Serrated Neoplasia: A Randomized Controlled Trial. Dig Dis Sci (2021). https://doi.org/10.1007/s10620-021-06858-x

Download citation

Keywords

  • Colonoscopy
  • Sessile serrated lesion
  • Polyp
  • Acetic acid
  • Chromoendoscopy