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Jiang SX, Shahidi N. Large non-pedunculated colorectal polyp management: The elephant in the room. World J Gastroenterol 2024; 30:3126-3131. [PMID: 39006383 PMCID: PMC11238671 DOI: 10.3748/wjg.v30.i25.3126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 05/19/2024] [Accepted: 06/11/2024] [Indexed: 07/01/2024] Open
Abstract
Minimally invasive innovations have transformed coloproctology. Specific to colorectal cancer (CRC), there has been a shift towards less invasive surgical techniques and use of endoscopic resection as an alternative for low risk T1 CRC. The role of endoscopic resection is however much more extensive: It is now considered the first line management strategy for most large (≥ 20 mm) non-pedunculated colorectal polyps, the majority of which are benign. This is due to the well-established efficacy, safety, and cost-effectiveness of endoscopic techniques compared to surgery. Multiple endoscopic modalities now exist with distinct risk-benefit profiles and their outcomes are further improved by site-specific technical modifications, auxiliary techniques, and adverse event mitigation strategies. Endoscopic capacity continues to evolve with emerging endoscopic techniques and expanding applications, particularly in the confines of a multi-disciplinary setting.
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Affiliation(s)
- Shirley X Jiang
- Department of Medicine, University of British Columbia, Vancouver V6Z 2K5, BC, Canada
| | - Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver V6Z 2K5, BC, Canada
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2
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O'Sullivan T, Cronin O, van Hattem WA, Mandarino FV, Gauci JL, Kerrison C, Whitfield A, Gupta S, Lee E, Williams SJ, Burgess N, Bourke MJ. Cold versus hot snare endoscopic mucosal resection for large (≥15 mm) flat non-pedunculated colorectal polyps: a randomised controlled trial. Gut 2024:gutjnl-2024-332807. [PMID: 38964854 DOI: 10.1136/gutjnl-2024-332807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 05/31/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND AND AIMS Conventional hot snare endoscopic mucosal resection (H-EMR) is effective for the management of large (≥20 mm) non-pedunculated colon polyps (LNPCPs) however, electrocautery-related complications may incur significant morbidity. With a superior safety profile, cold snare EMR (C-EMR) of LNPCPs is an attractive alternative however evidence is lacking. We conducted a randomised trial to compare the efficacy and safety of C-EMR to H-EMR. METHODS Flat, 15-50 mm adenomatous LNPCPs were prospectively enrolled and randomly assigned to C-EMR or H-EMR with margin thermal ablation at a single tertiary centre. The primary outcome was endoscopically visible and/or histologically confirmed recurrence at 6 months surveillance colonoscopy. Secondary outcomes were clinically significant post-EMR bleeding (CSPEB), delayed perforation and technical success. RESULTS 177 LNPCPs in 177 patients were randomised to C-EMR arm (n=87) or H-EMR (n=90). Treatment groups were equivalent for technical success 86/87 (98.9%) C-EMR versus H-EMR 90/90 (100%); p=0.31. Recurrence was significantly greater in C-EMR (16/87, 18.4% vs 1/90, 1.1%; relative risk (RR) 16.6, 95% CI 2.24 to 122; p<0.001).Delayed perforation (1/90 (1.1%) vs 0; p=0.32) only occurred in the H-EMR group. CSPEB was significantly greater in the H-EMR arm (7/90 (7.8%) vs 1/87 (1.1%); RR 6.77, 95% CI 0.85 to 53.9; p=0.034). CONCLUSION Compared with H-EMR, C-EMR for flat, adenomatous LNPCPs, demonstrates superior safety with equivalent technical success. However, endoscopic recurrence is significantly greater for cold snare resection and is currently a limitation of the technique. TRIAL REGISTRATION NUMBER NCT04138030.
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Affiliation(s)
- Timothy O'Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Francesco Vito Mandarino
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Julia L Gauci
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Clarence Kerrison
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Eric Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Nicholas Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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3
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Ferlitsch M, Hassan C, Bisschops R, Bhandari P, Dinis-Ribeiro M, Risio M, Paspatis GA, Moss A, Libânio D, Lorenzo-Zúñiga V, Voiosu AM, Rutter MD, Pellisé M, Moons LMG, Probst A, Awadie H, Amato A, Takeuchi Y, Repici A, Rahmi G, Koecklin HU, Albéniz E, Rockenbauer LM, Waldmann E, Messmann H, Triantafyllou K, Jover R, Gralnek IM, Dekker E, Bourke MJ. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2024. Endoscopy 2024; 56:516-545. [PMID: 38670139 DOI: 10.1055/a-2304-3219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
1: ESGE recommends cold snare polypectomy (CSP), to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of diminutive polyps (≤ 5 mm).Strong recommendation, high quality of evidence. 2: ESGE recommends against the use of cold biopsy forceps excision because of its high rate of incomplete resection.Strong recommendation, moderate quality of evidence. 3: ESGE recommends CSP, to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of small polyps (6-9 mm).Strong recommendation, high quality of evidence. 4: ESGE recommends hot snare polypectomy for the removal of nonpedunculated adenomatous polyps of 10-19 mm in size.Strong recommendation, high quality of evidence. 5: ESGE recommends conventional (diathermy-based) endoscopic mucosal resection (EMR) for large (≥ 20 mm) nonpedunculated adenomatous polyps (LNPCPs).Strong recommendation, high quality of evidence. 6: ESGE suggests that underwater EMR can be considered an alternative to conventional hot EMR for the treatment of adenomatous LNPCPs.Weak recommendation, moderate quality of evidence. 7: Endoscopic submucosal dissection (ESD) may also be suggested as an alternative for removal of LNPCPs of ≥ 20 mm in selected cases and in high-volume centers.Weak recommendation, low quality evidence. 8: ESGE recommends that, after piecemeal EMR of LNPCPs by hot snare, the resection margins should be treated by thermal ablation using snare-tip soft coagulation to prevent adenoma recurrence.Strong recommendation, high quality of evidence. 9: ESGE recommends (piecemeal) cold snare polypectomy or cold EMR for SSLs of all sizes without suspected dysplasia.Strong recommendation, moderate quality of evidence. 10: ESGE recommends prophylactic endoscopic clip closure of the mucosal defect after EMR of LNPCPs in the right colon to reduce to reduce the risk of delayed bleeding.Strong recommendation, high quality of evidence. 11: ESGE recommends that en bloc resection techniques, such as en bloc EMR, ESD, endoscopic intermuscular dissection, endoscopic full-thickness resection, or surgery should be the techniques of choice in cases with suspected superficial invasive carcinoma, which otherwise cannot be removed en bloc by standard polypectomy or EMR.Strong recommendation, moderate quality of evidence.
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Affiliation(s)
- Monika Ferlitsch
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Department of Gastroenterology, Evangelical Hospital, Vienna, Austria
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, KU Leuven, Leuven, Belgium
| | - Pradeep Bhandari
- Endoscopy Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
- MEDCIDS/Faculty of Medicine, University of Porto, Porto, Portugal
- Porto Comprehensive Cancer Center (Porto.CCC) and RISE@CI-IPOP (Health Research Network), Porto, Portugal
| | - Mauro Risio
- Department of Pathology, Institute for Cancer Research and Treatment, Candiolo, Turin, Italy
| | - Gregorios A Paspatis
- Gastroenterology Department, Venizeleio General Hospital, Heraklion, Crete, Greece
| | - Alan Moss
- Department of Gastroenterology, Western Health, Melbourne, Australia
- Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Diogo Libânio
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
- MEDCIDS/Faculty of Medicine, University of Porto, Porto, Portugal
- Porto Comprehensive Cancer Center (Porto.CCC) and RISE@CI-IPOP (Health Research Network), Porto, Portugal
| | - Vincente Lorenzo-Zúñiga
- Endoscopy Unit, La Fe University and Polytechnic Hospital / IISLaFe, Valencia, Spain
- Department of Medicine, Catholic University of Valencia, Valencia, Spain
| | - Andrei M Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
- Internal Medicine and Gastroenterology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Matthew D Rutter
- Department of Gastroenterology, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK
- Department of Gastroenterology, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, UK
| | - Maria Pellisé
- Department of Gastroenterology, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), University of Barcelona, Barcelona, Spain
| | - Leon M G Moons
- III Medizinische Klinik, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Andreas Probst
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany
| | - Halim Awadie
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Arnaldo Amato
- Digestive Endoscopy and Gastroenterology Department, Ospedale A. Manzoni, Lecco, Italy
| | - Yoji Takeuchi
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Gabriel Rahmi
- Hepatogastroenterology and Endoscopy Department, Hôpital européen Georges Pompidou, Paris, France
- Laboratoire de Recherches Biochirurgicales, APHP-Centre Université de Paris, Paris, France
| | - Hugo U Koecklin
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Teknon Medical Center, Barcelona, Spain
| | - Eduardo Albéniz
- Gastroenterology Department, Hospital Universitario de Navarra (HUN); Navarrabiomed, Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Lisa-Maria Rockenbauer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Waldmann
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Helmut Messmann
- III Medizinische Klinik, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodastrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Rodrigo Jover
- Servicio de Medicina Digestiva, Hospital General Universitario Dr. Balmis, Instituto de Investigación Sanitaria ISABIAL, Departamento de Medicina Clínica, Universidad Miguel Hernández, Alicante, Spain
| | - Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa, Israel
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
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Xu YJ, Huo YC, Zhao QT, Liu JY, Tian YJ, Yang LL, Zhang Y. NOX4 promotes tumor progression through the MAPK-MEK1/2-ERK1/2 axis in colorectal cancer. World J Gastrointest Oncol 2024; 16:1421-1436. [PMID: 38660653 PMCID: PMC11037073 DOI: 10.4251/wjgo.v16.i4.1421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/04/2024] [Accepted: 02/07/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Metabolic reprogramming plays a key role in cancer progression and clinical outcomes; however, the patterns and primary regulators of metabolic reprogramming in colorectal cancer (CRC) are not well understood. AIM To explore the role of nicotinamide adenine dinucleotide phosphate oxidase 4 (NOX4) in promoting progression of CRC. METHODS We evaluated the expression and function of dysregulated and survival-related metabolic genes using Gene Ontology and Kyoto Encyclopedia of Genes and Genomes. Consensus clustering was used to cluster CRC based on dysregulated metabolic genes. A prediction model was constructed based on survival-related metabolic genes. Sphere formation, migration, invasion, proliferation, apoptosis and clone formation was used to evaluate the biological function of NOX4 in CRC. mRNA sequencing was utilized to explore the alterations of gene expression NOX4 over-expression tumor cells. In vivo subcutaneous and lung metastasis mouse tumor model was used to explore the effect of NOX4 on tumor growth. RESULTS We comprehensively analyzed 3341 metabolic genes in CRC and identified three clusters based on dysregulated metabolic genes. Among these genes, NOX4 was highly expressed in tumor tissues and correlated with worse survival. In vitro, NOX4 overexpression induced clone formation, migration, invasion, and stemness in CRC cells. Furthermore, RNA-sequencing analysis revealed that NOX4 overexpression activated the mitogen-activated protein kinase-MEK1/2-ERK1/2 signaling pathway. Trametinib, a MEK1/2 inhibitor, abolished the NOX4-mediated tumor progression. In vivo, NOX4 overexpression promoted subcutaneous tumor growth and lung metastasis, whereas trametinib treatment can reversed the metastasis. CONCLUSION Our study comprehensively analyzed metabolic gene expression and highlighted the importance of NOX4 in promoting CRC metastasis, suggesting that trametinib could be a potential therapeutic drugs of CRC clinical therapy targeting NOX4.
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Affiliation(s)
- Yu-Jie Xu
- Biotherapy Center and Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
- Department of Oncology, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, People’s Hospital of Henan University, Zhengzhou 450003, Henan Province, China
| | - Ya-Chang Huo
- Biotherapy Center and Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Qi-Tai Zhao
- Biotherapy Center and Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Jin-Yan Liu
- Biotherapy Center and Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Yi-Jun Tian
- Biotherapy Center and Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Lei-Lei Yang
- Biotherapy Center and Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
| | - Yi Zhang
- Biotherapy Center and Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan Province, China
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5
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Haghbin H, Zakirkhodjaev N, Fatima R, Kamal F, Aziz M. Efficacy and Safety of Thermal Ablation after Endoscopic Mucosal Resection: A Systematic Review and Network Meta-Analysis. J Clin Med 2024; 13:1298. [PMID: 38592137 PMCID: PMC10932371 DOI: 10.3390/jcm13051298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/20/2024] [Accepted: 02/23/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: Large colonic polyps during colonoscopy can be managed by Endoscopic mucosal resection (EMR). To decrease the polyp recurrence rate, thermal ablation methods like argon plasma coagulation (APC) and snare tip soft coagulation (STSC) have been introduced. We performed this network meta-analysis to assess the efficacy and safety of these modalities. (2) Methods: We performed a comprehensive literature review, through 5 January 2024, of databases including Embase, PubMed, SciELO, KCI, Cochrane Central, and Web of Science. Using a random effects model, we conducted a frequentist approach network meta-analysis. The risk ratio (RR) with 95% confidence interval (CI) was calculated. Safety and efficacy endpoints including rates of recurrence, bleeding, perforation, and post polypectomy syndrome were compared. (3) Results: Our search yielded a total of 13 studies with 2686 patients. Compared to placebo, both APC (RR: 0.33 CI: 0.20-0.54, p < 0.01) and STSC (RR: 0.27, CI: 0.21-0.34, p < 0.01) showed decreased recurrence rates. On ranking, STSC showed the lowest recurrence rate, followed by APC and placebo. Regarding individual adverse events, there was no statistically significant difference between either of the thermal ablation methods and placebo. (4) Conclusions: We demonstrated the efficacy and safety of thermal ablation after EMR for decreasing recurrence of adenoma.
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Affiliation(s)
- Hossein Haghbin
- Division of Gastroenterology, Ascension Providence Hospital, Southfield, MI 48075, USA
| | - Nuruddinkhodja Zakirkhodjaev
- Division of Occupational and Environmental Medicine, The University of Texas Health Science Center at Houston, Houston, TX 77021, USA;
| | - Rawish Fatima
- Division of Rheumatology, University of Toledo, Toledo, OH 43606, USA;
| | - Faisal Kamal
- Division of Gastroenterology, Thomas Jefferson University, Philadelphia, PA 19144, USA;
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, Bon Secours Mercy Health, Toledo, OH 43608, USA;
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Mohammed A, Gonzaga ER, Hasan MK, Saeed A, Friedland S, Bilal M, Sharma N, Jawaid S, Othman M, Khalaf MA, Hwang JH, Viana A, Singh S, Hayat M, Cosgrove ND, Jain D, Arain MA, Kadkhodayan KS, Yang D. Low delayed bleeding and high complete closure rate of mucosal defects with the novel through-the-scope dual-action tissue clip after endoscopic resection of large nonpedunculated colorectal lesions (with video). Gastrointest Endosc 2024; 99:83-90.e1. [PMID: 37481003 DOI: 10.1016/j.gie.2023.07.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/05/2023] [Accepted: 07/17/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND AND AIMS Complete closure after endoscopic resection of large nonpedunculated colorectal lesions (LNPCLs) can reduce delayed bleeding but is challenging with conventional through-the-scope (TTS) clips alone. The novel dual-action tissue (DAT) clip has clip arms that open and close independently of each other, facilitating tissue approximation. We aimed to evaluate the rate of complete closure and delayed bleeding with the DAT clip after endoscopic resection of LNPCLs. METHODS This was a multicenter prospective cohort study of all patients who underwent defect closure with the DAT clip after EMR or endoscopic submucosal dissection (ESD) of LNPCLs ≥20 mm from July 2022 to May 2023. Delayed bleeding was defined as a bleeding event requiring hospitalization, blood transfusion, or any intervention within 30 days after the procedure. Complete closure was defined as apposition of mucosal defect margins without visible submucosal areas <3 mm along the closure line. RESULTS One hundred seven patients (median age, 64 years; 42.5% women) underwent EMR (n = 63) or ESD (n = 44) of LNPCLs (median size, 40 mm; 74.8% right-sided colon) followed by defect closure. Complete closure was achieved in 96.3% (n = 103) with a mean of 1.4 ± .6 DAT clips and 2.9 ± 1.8 TTS clips. Delayed bleeding occurred in 1 patient (.9%) without requiring additional interventions. CONCLUSIONS The use of the DAT clip in conjunction with TTS clips achieved high complete defect closure after endoscopic resection of large LNPCLs and was associated with a .9% delayed bleeding rate. Future comparative trials and formal cost-analyses are needed to validate these findings. (Clinical trial registration number: NCT05852457.).
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Affiliation(s)
- Abdul Mohammed
- Division of Gastroenterology and Hepatology, AdventHealth, Orlando, Florida, USA
| | | | - Muhammad K Hasan
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Ahmed Saeed
- Kansas City Gastroenterology and Hepatology Physicians Group, Kansas City, Missouri, USA
| | - Shai Friedland
- Department of Gastroenterology, Stanford University School of Medicine, Stanford, California, USA; VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Mohammad Bilal
- The University of Minnesota/Minneapolis VA Medical Center, Minneapolis, Minnesota, USA
| | - Neil Sharma
- Division of Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Cancer Institute, Fort Wayne, Indiana, USA
| | - Salmaan Jawaid
- Division of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Mohamed Othman
- Division of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Mai Ahmed Khalaf
- Division of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Joo Ha Hwang
- Department of Gastroenterology, Stanford University School of Medicine, Stanford, California, USA
| | - Artur Viana
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Sanmeet Singh
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Maham Hayat
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Natalie D Cosgrove
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Deepanshu Jain
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Mustafa A Arain
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | | | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
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7
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Gupta S, Kurup R, Shahidi N, Vosko S, McKay O, Zahid S, Whitfield A, Lee EY, Williams SJ, Burgess NG, Bourke MJ. Safety and efficacy of physician-administered balanced-sedation for the endoscopic mucosal resection of large non-pedunculated colorectal polyps. Endosc Int Open 2024; 12:E1-E10. [PMID: 38188923 PMCID: PMC10769574 DOI: 10.1055/a-2180-8880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 08/17/2023] [Indexed: 01/09/2024] Open
Abstract
Background and study aims Because of concerns about peri-procedural adverse events (AEs), guidelines recommend anesthetist-managed sedation (AMS) for long and complex endoscopic procedures. The safety and efficacy of physician-administered balanced sedation (PA-BS) for endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (LNPCPs) ≥20 mm is unknown. Patients and methods We compared PA-BS with AMS in a retrospective study of prospectively collected data from consecutive patients referred for management of LNPCPs (NCT01368289; NCT02000141). A per-patient propensity analysis was performed following a 1:2 nearest-neighbor (Greedy-type) match, based on age, gender, Charlson comorbidity index, and lesion size. The primary outcome was any peri-procedural AE, which included hypotension, hypertension, tachycardia, bradycardia, hypoxia, and new arrhythmia. Secondary outcomes were unplanned admissions, 28-day re-presentation, technical success, and recurrence. Results Between January 2016 and June 2020, 700 patients underwent EMR for LNPCPs, of whom 638 received PA-BS. Among them, the median age was 70 years (interquartile range [IQR] 62-76 years), size 35 mm (IQR 25-45 mm), and duration 35 minutes (IQR 25-60 minutes). Peri-procedural AEs occurred in 149 (23.4%), most commonly bradycardia (116; 18.2%). Only five (0.8%) required an unplanned sedation-related admission due to AEs (2 hypotension, 1 arrhythmia, 1 bradycardia, 1 hypoxia), with a median inpatient stay of 1 day (IQR 1-3 days). After propensity-score matching, there were no differences between PA-BS and AMS in peri-procedural AEs, unplanned admissions, 28-day re-presentation rates, technical success or recurrence. Conclusions Physician-administered balanced sedation for the EMR of LNPCPs is safe. Peri-procedural AEs are infrequent, transient, rarely require admission (<1%), and are experienced in similar frequencies to those receiving anesthetist-managed sedation.
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Affiliation(s)
- Sunil Gupta
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
| | - Rajiv Kurup
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
| | - Neal Shahidi
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
- Gastroenterology and Hepatology, The University of British Columbia Faculty of Medicine, Vancouver, Canada
| | - Sergei Vosko
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
| | - Owen McKay
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
| | - Simmi Zahid
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
| | - Anthony Whitfield
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
| | - Eric Y. Lee
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
| | | | - Nicholas Graeme Burgess
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
| | - Michael J. Bourke
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
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O'Sullivan T, Sidhu M, Gupta S, Byth K, Elhindi J, Tate D, Cronin O, Whitfield A, Wang H, Lee E, Williams S, Burgess NG, Bourke MJ. A novel tool for case selection in endoscopic mucosal resection training. Endoscopy 2023; 55:1095-1102. [PMID: 37391184 DOI: 10.1055/a-2121-1148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
BACKGROUND As endoscopic mucosal resection (EMR) of large (≥ 20 mm) adenomatous nonpedunculated colonic polyps (LNPCPs) becomes widely practiced outside expert centers, appropriate training is necessary to avoid failed resection and inappropriate surgical referral. No EMR-specific tool guides case selection for endoscopists learning EMR. This study aimed to develop an EMR case selection score (EMR-CSS) to identify potentially challenging lesions for "EMR-naïve" endoscopists developing competency. METHODS Consecutive EMRs were recruited from a single center over 130 months. Lesion characteristics, intraprocedural data, and adverse events were recorded. Challenging lesions with intraprocedural bleeding (IPB), intraprocedural perforation (IPP), or unsuccessful resection were identified and predictive variables identified. Significant variables were used to form a numerical score and receiver operating characteristic curves were used to generate cutoff values. RESULTS Of 1993 LNPCPs, 286 (14.4 %) were in challenging locations (anorectal junction, ileocecal valve, or appendiceal orifice), 368 (18.5 %) procedures were complicated by IPB and 77 (3.9 %) by IPP; 110 (5.5 %) procedures were unsuccessful. The composite end point of IPB, IPP, or unsuccessful EMR was present in 526 cases (26.4 %). Lesion size, challenging location, and sessile morphology were predictive of the composite outcome. A six-point score was generated with a cutoff value of 2 demonstrating 81 % sensitivity across the training and validation cohorts. CONCLUSIONS The EMR-CSS is a novel case selection tool for conventional EMR training, which identifies a subset of adenomatous LNPCPs that can be successfully and safely attempted in early EMR training.
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Affiliation(s)
- Timothy O'Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Karen Byth
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, New South Wales, Australia
- The NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - James Elhindi
- Research and Education Network, Western Sydney Local Health District, Westmead Hospital, Sydney, New South Wales, Australia
- Reproduction and Perinatal Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - David Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- University of Ghent, Ghent, Belgium
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium
| | - Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Hunter Wang
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Eric Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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de Paula MC, Carvalho SG, Silvestre ALP, Dos Santos AM, Meneguin AB, Chorilli M. The role of hyaluronic acid in the design and functionalization of nanoparticles for the treatment of colorectal cancer. Carbohydr Polym 2023; 320:121257. [PMID: 37659830 DOI: 10.1016/j.carbpol.2023.121257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/11/2023] [Accepted: 08/01/2023] [Indexed: 09/04/2023]
Abstract
Despite advances in new approaches for colorectal cancer (CRC) therapy, intravenous chemotherapy remains one of the main treatment options; however, it has limitations associated with off-target toxicity, tumor cell resistance due to molecular complexity and CRC heterogeneity, which lead to tumor recurrence and metastasis. In oncology, nanoparticle-based strategies have been designed to avoid systemic toxicity and increase drug accumulation at tumor sites. Hyaluronic acid (HA) has obtained significant attention thanks to its ability to target nanoparticles (NPs) to CRC cells through binding to cluster-determinant-44 (CD44) and hyaluronan-mediated motility (RHAMM) receptors, along with its efficient biological properties of mucoadhesion. This review proposes to discuss the state of the art in HA-based nanoparticulate systems intended for localized treatment of CRC, highlighting the importance of the mucoadhesion and active targeting provided by this polymer. In addition, an overview of CRC will be provided, emphasizing the importance of CD44 and RHAMM receptors in this type of cancer and the current challenges related to this disease, and important concepts about the physicochemical and biological properties of HA will also be addressed. Finally, this review aims to contribute to the advancement of accuracy treatment of CRC by the design of new platforms based on by HA.
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Affiliation(s)
- Mariana Carlomagno de Paula
- Department of Drugs and Pharmaceutics, School of Pharmaceutical Sciences, São Paulo State University (UNESP), 14800-903 Araraquara, SP, Brazil.
| | - Suzana Gonçalves Carvalho
- Department of Drugs and Pharmaceutics, School of Pharmaceutical Sciences, São Paulo State University (UNESP), 14800-903 Araraquara, SP, Brazil.
| | - Amanda Letícia Polli Silvestre
- Department of Drugs and Pharmaceutics, School of Pharmaceutical Sciences, São Paulo State University (UNESP), 14800-903 Araraquara, SP, Brazil.
| | - Aline Martins Dos Santos
- Department of Drugs and Pharmaceutics, School of Pharmaceutical Sciences, São Paulo State University (UNESP), 14800-903 Araraquara, SP, Brazil.
| | - Andréia Bagliotti Meneguin
- Department of Drugs and Pharmaceutics, School of Pharmaceutical Sciences, São Paulo State University (UNESP), 14800-903 Araraquara, SP, Brazil.
| | - Marlus Chorilli
- Department of Drugs and Pharmaceutics, School of Pharmaceutical Sciences, São Paulo State University (UNESP), 14800-903 Araraquara, SP, Brazil.
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10
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Gupta S, Vosko S, Shahidi N, O'Sullivan T, Cronin O, Whitfield A, Kurup R, Sidhu M, Lee EYT, Williams SJ, Burgess NG, Bourke MJ. Endoscopic resection-related colorectal strictures: risk factors, management, and long-term outcomes. Endoscopy 2023; 55:1010-1018. [PMID: 37279786 DOI: 10.1055/a-2106-6494] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Colorectal strictures related to endoscopic resection (ER) of large nonpedunculated colorectal polyps (LNPCPs) may be problematic. Data on prevalence, risk factors, and management are limited. We report a prospective study of colorectal strictures following ER and describe our approach to management. METHODS We analyzed prospectively collected data over 150 months, until June 2021, for patients who underwent ER for LNPCPs ≥ 40 mm. The ER defect size was graded as < 60 %, 60 %-89 %, or ≥ 90 % of the luminal circumference. Strictures were considered "severe" if patients experienced obstructive symptoms, "moderate" if an adult colonoscope could not pass the stenosis, or "mild" if there was resistance on successful passage. Primary outcomes included stricture prevalence, risk factors, and management. RESULTS 916 LNPCPs ≥ 40 mm in 916 patients were included (median age 69 years, interquartile range 61-76 years, male sex 484 [52.8 %]). The primary resection modality was endoscopic mucosal resection in 859 (93.8 %). Risk of stricture formation with an ER defect ≥ 90 %, 60 %-89 %, and < 60 % was 74.2 % (23/31), 25.0 % (22/88), and 0.8 % (6 /797), respectively. Severe strictures only occurred with ER defects ≥ 90 % (22.6 %, 7/31). Defects < 60 % conferred low risk of only mild strictures (0.8 %, 6/797). Severe strictures required earlier (median 0.9 vs. 4.9 months; P = 0.01) and more frequent (median 3 vs. 2; P = 0.02) balloon dilations than moderate strictures. CONCLUSION Most patients with ER defects ≥ 90 % of luminal circumference developed strictures, many of which were severe and required early balloon dilation. There was minimal risk with ER defects < 60 %.
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Affiliation(s)
- Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Timothy O'Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Rajiv Kurup
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Westmead Clinical School, Sydney, Australia
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Sakowitz S, Bakhtiyar SS, Mallick S, Khoraminejad B, Olmedo M, Croman M, Benharash P, Lee H. Decreasing rates of colectomy for benign neoplasms: A nationwide analysis. PLoS One 2023; 18:e0293389. [PMID: 37878628 PMCID: PMC10599571 DOI: 10.1371/journal.pone.0293389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/25/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Despite advances in endoscopic techniques for management of benign colonic neoplasms, a rise in rates of surgical treatment has been reported. We used a nationally representative cohort to characterize temporal trends, patient characteristics, and outcomes associated with colectomy for colonic neoplasms. METHODS All patients undergoing elective partial colectomy for benign or malignant colonic neoplasms were identified using the 2012-2019 National Inpatient Sample. Those presenting with inflammatory bowel disease, or experiencing intestinal perforation were excluded. Patients with benign neoplasms were classified as the Benign cohort (others: Malignant). Trends, characteristics, and outcomes were assessed between groups. RESULTS Of 569,280 colectomy procedures included for analysis, 153,435 (27.0%) were performed for benign lesions. The proportion of Benign operations decreased from 28.6% in 2012 to 23.7% in 2019 (P for trend<0.001). While overall national incidence of colectomy for benign neoplasms decreased from 2012 to 2019 (IRD -1.19, 95%CI -1.20- -1.19), Black patients demonstrated an incremental increase (IRD +0.04, 95%CI +0.02-0.06). On average, Benign was younger (66 [57-72] vs 68 years [58-77], P<0.001), and demonstrated a lower Elixhauser comorbidity index (2 [1-3] vs 3 [2-4], P<0.001), relative to Malignancy. Following adjustment, Benign demonstrated lower odds of in-hospital mortality (AOR 0.61, 95%CI 0.50-0.74; P<0.001), stoma creation (AOR 0.46, 95%CI 0.43-0.50; P<0.001), and infectious complications (AOR 0.68, 95%CI 0.63-0.73; P<0.001). CONCLUSIONS The present national study identifies a decrease in colectomy for benign polyps from 2012-2019. Future investigations should identify patients who would most benefit from surgical resection and address persistent inequities in access to screening and treatment for colonic neoplasms.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
- Department of Surgery, University of Colorado, Aurora, CO, United States of America
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Baran Khoraminejad
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Manuel Olmedo
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Millicent Croman
- Department of Surgery, University of California, Los Angeles, CA, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
- Department of Surgery, University of California, Los Angeles, CA, United States of America
| | - Hanjoo Lee
- Department of Surgery, University of California, Los Angeles, CA, United States of America
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12
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Stojic V, Zdravkovic N, Nikolic-Turnic T, Zdravkovic N, Dimitrijevic J, Misic A, Jovanovic K, Milojevic S, Zivic J. Using of endoscopic polypectomy in patients with diagnosed malignant colorectal polyp - The cross-sectional clinical study. Open Med (Wars) 2023; 18:20230811. [PMID: 37873541 PMCID: PMC10590616 DOI: 10.1515/med-2023-0811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 09/02/2023] [Accepted: 09/05/2023] [Indexed: 10/25/2023] Open
Abstract
The aim of this study was to evaluate the efficacy of endoscopic polypectomy as a therapeutic treatment for malignant alteration of colorectal polyps. In a 5-year research, 89 patients were included, who were tested and treated at the University Clinical Center Kragujevac, Kragujevac, Serbia, with the confirmed presence of malignant alteration polyps of the colon by colonoscopy, which were removed using the method of endoscopic polypectomy and confirmed by the histopathological examination of the entire polyp. After that, the same group of patients was monitored endoscopically within a certain period, controlling polypectomy locations and the occurrence of a possible remnant of the polyp, in the period of up to 2 years of polypectomy. We observed that, with an increasing size of polyps, there is also an increase in the percentage of the complexity of endoscopic resection and the appearance of remnant with histological characteristics of the invasive cancer. The highest percentage of incomplete endoscopic resection and the appearance of remnant with histological characteristics of the invasive cancer were shown at malignant altered polyps in the field of tubulovillous adenoma. Eighteen patients in total underwent the surgical intervention. In conclusion, our data support the high efficacy of endoscopic polypectomy for the removal of the altered malignant polyp.
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Affiliation(s)
- Vladislava Stojic
- Department of Medical Statistics and Informatics, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Natasa Zdravkovic
- Department of Internal Medicine, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Tamara Nikolic-Turnic
- Department of Pharmacy, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Nebojsa Zdravkovic
- Department of Medical Statistics and Informatics, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Jelena Dimitrijevic
- Department of Medical Statistics and Informatics, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Aleksandra Misic
- Department of Dentistry, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Kristijan Jovanovic
- Department of Anatomy, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Stefan Milojevic
- Faculty of Business Economics, EDUCONS University, Sremska Kamenica, Serbia
| | - Jelena Zivic
- Department of Internal Medicine, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
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13
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Shi K, Yang Z, Leng K. Treatment for T1 colorectal cancers substratified by site and size: "horses for courses". Front Med (Lausanne) 2023; 10:1230844. [PMID: 37901402 PMCID: PMC10602675 DOI: 10.3389/fmed.2023.1230844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/21/2023] [Indexed: 10/31/2023] Open
Abstract
Background Owing to advances in diagnostic technology, the diagnosis of T1 colorectal cancers (CRCs) continues to increase. However, the optimal management of T1 CRCs in the Western Hemisphere remains unclear due to limited population-based data directly comparing the efficacy of endoscopic therapy (ET) and surgical resection (SR). The purpose of this study was to report outcome data from a large Western cohort of patients who underwent ET or SR for early CRCs. Methods The SEER-18 database was used to identify patients with T1 CRCs diagnosed from 2004 to 2018 treated with ET or SR. Multivariable logistic regression models were employed to identify variables related to lymph node metastasis (LNM). Rates of ET and 1-year relative survival were calculated for each year. Effect of ET or SR on overall survival and cancer-specific survival was compared using Kaplan-Meier method stratified by tumor size and site. Results A total of 28,430 T1 CRCs patients were identified from 2004 to 2018 in US, with 22.7% undergoing ET and 77.3% undergoing SR. The incidence of T1 CRCs was 6.15 per 100,000 person-years, with male patients having a higher incidence. Left-sided colon was the most frequent location of tumors. The utilization of ET increased significantly from 2004 to 2018, with no significant change in 1-year relative survival rate. Predictors of LNM were age at diagnosis, sex, race, tumor size, histology, grade, and location. The 5-year relative survival rates were 91.4 and 95.4% for ET and SR, respectively. Subgroup analysis showed that OS and CSS were similar between ET and SR in T1N0M0 left-sided colon cancers with tumors 2 cm or less and in rectal cancers with tumors 1 cm or less. Conclusion Our study showed that ET was feasible and safe for patients with left-sided T1N0M0 colon cancers and tumors of 2 cm or less, as well as T1N0M0 rectal cancers and tumors of 1 cm or less. Therefore, the over- and under-use of ET should be avoided by carefully selecting patients based on tumor size and site.
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Affiliation(s)
- Kexin Shi
- The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Zhen Yang
- Department of Hepatopancreatobiliary Surgery, Qingdao Municipal Hospital, Qingdao University, Qingdao, China
- Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, China
| | - Kaiming Leng
- Department of Hepatopancreatobiliary Surgery, Qingdao Municipal Hospital, Qingdao University, Qingdao, China
- Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, China
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14
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Blasberg T, Hochberger J, Meiborg M, Jung C, Weber M, Brunk T, Leifeld L, Seif Amir Hosseini A, Wedi E. Prophylactic clipping using the over-the-scope clip (OTSC) system after complex ESD and EMR of large colon polyps. Surg Endosc 2023; 37:7520-7529. [PMID: 37418148 DOI: 10.1007/s00464-023-10235-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/18/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Delayed bleeding is the most frequent complication after endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) of large colon polyps. Today, prophylactic clipping with through-the-scope clips (TTSCs) is commonly used to reduce the risk of bleeding. However, the over-the-scope clip (OTSC) system might be superior to TTSCs in achieving hemostasis. This study aims to evaluate the efficacy and safety of prophylactic clipping using the OTSC system after ESD or EMR of large colon polyps. METHODS This is a retrospective analysis of a prospective collected database from 2009 until 2021 of three endoscopic centers. Patients with large (≥ 20 mm) colon polyps were enrolled. All polyps were removed by either ESD or EMR. After the resection, OTSCs were prophylactically applied on parts of the mucosal defect with a high risk of delayed bleeding or/and perforation. The main outcome measurement was delayed bleeding. RESULTS A total of 75 patients underwent ESD (67%, 50/75) or EMR (33%, 25/75) in the colorectum. The mean resected specimen diameter was 57 mm ± 24.1 (range 22-98 mm). The mean number of OTSCs placed on the mucosal defect was 2 (range 1-5). None of the mucosal defects were completely closed. Intraprocedural bleeding occurred in 5.3% (ESD 2.0% vs. EMR 12.0%; P = 0.105), and intraprocedural perforation occurred in 6.7% (ESD 8% vs. EMR 4%; P = 0.659) of the patients. Hemostasis was achieved in 100% of cases of intraprocedural bleeding, whereas two patients required surgical conversion due to intraprocedural perforation. Among the remaining 73 patients who received prosphylactic clipping, delayed bleeding occurred in 1.4% (ESD 0% vs. EMR 4.2%; P = 0.329), and delayed perforation occurred in 0%. CONCLUSIONS The prophylactic partial closure of large post-ESD/EMR mucosal defects using OTSCs could serve as an effective strategy to reduce the risk of delayed bleeding and perforation. The prophylactic partial closure of large complex post-ESD/EMR mucosal defects using OTSCs could serve as an effective strategy to reduce the risk of delayed bleeding and perforation.
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Affiliation(s)
- T Blasberg
- Division of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Starkenburgring 66, 63069, Offenbach, Germany
| | - J Hochberger
- Department of Gastroenterology, Vivantes Hospital Friedrichshain Berlin, Berlin, Germany
| | - M Meiborg
- Division of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Starkenburgring 66, 63069, Offenbach, Germany
| | - C Jung
- Clinic for Gastroenterology, Gastrointestinal Oncology and Endocrinology, University of Göttingen, Göttingen, Germany
| | - M Weber
- Division of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Starkenburgring 66, 63069, Offenbach, Germany
| | - T Brunk
- Department of Gastroenterology, Vivantes Hospital Friedrichshain Berlin, Berlin, Germany
| | - L Leifeld
- Department of Internal Medicine III, St. Bernward Hospital, Hildesheim, Germany
| | - A Seif Amir Hosseini
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Göttingen, Germany
| | - E Wedi
- Division of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Starkenburgring 66, 63069, Offenbach, Germany.
- Clinic for Gastroenterology, Gastrointestinal Oncology and Endocrinology, University of Göttingen, Göttingen, Germany.
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15
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Tate DJ, Desomer L, Argenziano ME, Mahajan N, Sidhu M, Vosko S, Shahidi N, Lee E, Williams SJ, Burgess NG, Bourke MJ. Treatment of adenoma recurrence after endoscopic mucosal resection. Gut 2023; 72:1875-1886. [PMID: 37414440 DOI: 10.1136/gutjnl-2023-330300] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 05/29/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE Residual or recurrent adenoma (RRA) after endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (LNPCPs) of ≥20 mm is a major limitation. Data on outcomes of the endoscopic treatment of recurrence are scarce, and no evidence-based standard exists. We investigated the efficacy of endoscopic retreatment over time in a large prospective cohort. DESIGN Over 139 months, detailed morphological and histological data on consecutive RRA detected after EMR for single LNPCPs at one tertiary endoscopy centre were prospectively recorded during structured surveillance colonoscopy. Endoscopic retreatment was performed on cases with evidence of RRA and was performed predominantly using hot snare resection, cold avulsion forceps with adjuvant snare tip soft coagulation or a combination of the two. RESULTS 213 (14.6%) patients had RRA (168 (78.9%) at first surveillance and 45 (21.1%) thereafter). RRA was commonly 2.5-5.0 mm (48.0%) and unifocal (78.7%). Of 202 (94.8%) cases which had macroscopic evidence of RRA, 194 (96.0%) underwent successful endoscopic therapy and 161 (83.4%) had a subsequent follow-up colonoscopy. Of the latter, endoscopic therapy of recurrence was successful in 149 (92.5%) of 161 in the per-protocol analysis, and 149 (73.8%) of 202 in the intention-to-treat analysis, with a mean of 1.15 (SD 0.36) retreatment sessions. No adverse events were directly attributable to endoscopic therapy. Further RRA after endoscopic therapy was endoscopically treatable in most cases. Overall, only 9 (4.2%, 95% CI 2.2% to 7.8%) of 213 patients with RRA required surgery.Thus 159 (98.8%, 95% CI 95.1% to 99.8%) of 161 cases with initially successful endoscopic treatment of RRA and follow-up remained surgery-free for a median of 13 months (IQR 25.0) of follow-up. CONCLUSIONS RRA after EMR of LNPCPs can be effectively treated using simple endoscopic techniques with long-term adenoma remission of >90%; only 16% required retreatment. Therefore, more technically complex, morbid and resource-intensive endoscopic or surgical techniques are required only in selected cases. TRIAL REGISTRATION NUMBERS NCT01368289 and NCT02000141.
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Affiliation(s)
- David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Gent, Belgium
- Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Lobke Desomer
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Maria Eva Argenziano
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Gent, Belgium
| | - Neha Mahajan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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16
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Cronin O, Bourke MJ. Endoscopic Management of Large Non-Pedunculated Colorectal Polyps. Cancers (Basel) 2023; 15:3805. [PMID: 37568621 PMCID: PMC10417738 DOI: 10.3390/cancers15153805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 08/13/2023] Open
Abstract
Large non-pedunculated colorectal polyps ≥20 mm (LNPCPs) comprise approximately 1% of all colorectal polyps. LNPCPs more commonly contain high-grade dysplasia, covert and overt cancer. These lesions can be resected using several means, including conventional endoscopic mucosal resection (EMR), cold-snare EMR (C-EMR) and endoscopic submucosal dissection (ESD). This review aimed to provide a comprehensive, critical and objective analysis of ER techniques. Evidence-based, selective resection algorithms should be used when choosing the most appropriate technique to ensure the safe and effective removal of LNPCPs. Due to its enhanced safety and comparable efficacy, there has been a paradigm shift towards cold-snare polypectomy (CSP) for the removal of small polyps (<10 mm). This technique is now being applied to the management of LNPCPs; however, further research is required to define the optimal LNPCP subtypes to target and the viable upper size limit. Adjuvant techniques, such as thermal ablation of the resection margin, significantly reduce recurrence risk. Bleeding risk can be mitigated using through-the-scope clips to close defects in the right colon. Endoscopic surveillance is important to detect recurrence and synchronous lesions. Recurrence can be readily managed using an endoscopic approach.
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Affiliation(s)
- Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW 2145, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW 2145, Australia
| | - Michael J. Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW 2145, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW 2145, Australia
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Zhong Y, Jian GL, Li QX, Xiao YY, Ye JY, Liu QX, Zhong MY, Ni D, Pei XQ, Huang WJ. Abdominal Ultrasonography After Transrectal Filling With Contrast Agents in Colorectal Cancer With Severely Stenotic Lesions. ULTRASOUND IN MEDICINE & BIOLOGY 2023:S0301-5629(23)00206-5. [PMID: 37423829 DOI: 10.1016/j.ultrasmedbio.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 05/26/2023] [Accepted: 06/14/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVE Abdominal ultrasonography after transrectal filling with contrast agent (AU-TFCA) was retrospectively evaluated with respect to determination of T stage and lesion length in patients with colorectal cancer (CRC) who had previously failed colonoscopy because of severe intestinal stenosis. METHODS The population comprised 83 patients with CRC with intestinal stenosis and previously failed colonoscopy who underwent AU-TFCA, and in addition contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI), 2 wk before surgery. The diagnostic performance of AU-TFCA and CECT/MRI was evaluated relative to the post-operative pathological results (PPRs) by paired sample t-test, receiver operator characteristic (ROC) curve, Pearson's χ2-test and κ and intraclass correlation coefficients. RESULTS The T staging identified via AU-TFCA, but not CECT/MRI, was relatively consistent with that of the PPRs (linearly weighted κ coefficient: 0.558, p < 0.001, and linearly weighted κ coefficient: 0.237, p < 0.001, respectively). The overall diagnostic accuracy of T staging based on AU-TFCA (83.1%) was significantly higher than that based on CECT/MRI (50.6%). Regarding lesion length, the results of AU-TFCA and PPRs were comparable (t = 1.852, p = 0.068), but those of CECT/MRI and PPRs were significantly different (t = 8.450, p < 0.001). CONCLUSION AU-TFCA is effective in evaluation of lesion length and T stage in patients with severely stenotic CRC lesions who previously failed colonoscopy. The diagnostic accuracy of AU-TFCA is significantly better compared with that of CECT/MRI.
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Affiliation(s)
- Yuan Zhong
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China
| | - Guo-Liang Jian
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China
| | - Qin-Xiang Li
- Department of Medical Radiology, First People's Hospital of Foshan, Foshan, China
| | - Yan-Yan Xiao
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China
| | - Jie-Yi Ye
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China
| | - Qin-Xue Liu
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China
| | - Min-Ying Zhong
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China
| | - Dong Ni
- Shenzhen University, Faculty of Medicine, School of Biomedical Engineering, Nanshan District, Shenzhen, China
| | - Xiao-Qing Pei
- Department of Medical Ultrasound, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Wei-Jun Huang
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China.
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18
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Lang X, Guo J, Li Y, Yang F, Feng X. A Bibliometric Analysis of Diagnosis Related Groups from 2013 to 2022. Risk Manag Healthc Policy 2023; 16:1215-1228. [PMID: 37425618 PMCID: PMC10325849 DOI: 10.2147/rmhp.s417672] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/24/2023] [Indexed: 07/11/2023] Open
Abstract
Purpose As an important management method of the global healthcare system, diagnosis related groups (DRGs) classify patients into different cost groups and pay more attention to the equitable distribution of medical resources and the quality of medical services. At present, most countries have used DRGs to help medical institutions and doctors to treat patients more accurately, avoid the waste of medical resources, and improve treatment efficiency. Methods The Web of Science database was searched to collect all relevant literature on DRGs from 2013 to 2022. The literature information was imported into CiteSpace, Vosviewer, and Histcite for data analysis and visualization of the results. Analyze the cooperative relationship among the countries, institutions, journals, and authors. The usage trend of keywords; Highlight the content of the cited articles. Results The number of articles published in this decade was stable, and the number of citations in 2014 was the highest. The United States and Germany, as the first countries to use the DRGs system, are ahead of other countries in terms of the number and quality of articles. We have carried out content research on the articles with high citations, and summarized the application range of DRGs; classification method; advantages and disadvantages of the application. In general, the development trend of DRGs in foreign countries is to continuously optimize the classification method, expand the scope of application, and improve the application effect. These provide support and reference for the improvement of medical services and the perfection of the medical insurance system. Conclusion The application of DRGs can improve the quality and efficiency of medical services, and reduce the waste of medical expenses. It can also promote the rational allocation of medical resources and the equity of medical services. In the future, DRGs will pay more attention to the personalized diagnosis and treatment and fine management of patients, and the sharing and standardization of medical data, to promote the development of medical informatization.
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Affiliation(s)
- Xiaona Lang
- Pharmacy Department, Tianjin Hospital, Tianjin, People’s Republic of China
| | - Jinming Guo
- Pharmacy Department, Tianjin Hospital, Tianjin, People’s Republic of China
| | - Yuntao Li
- Integrative Chinese and Western Medicine Department, Tianjin Hospital, Tianjin, People’s Republic of China
| | - Fan Yang
- Pharmacy Department, Tianjin Hospital, Tianjin, People’s Republic of China
| | - Xin Feng
- Pharmacy Department, Tianjin Hospital, Tianjin, People’s Republic of China
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Tate DJ, Argenziano ME, Anderson J, Bhandari P, Boškoski I, Bugajski M, Desomer L, Heitman SJ, Kashida H, Kriazhov V, Lee RRT, Lyutakov I, Pimentel-Nunes P, Rivero-Sánchez L, Thomas-Gibson S, Thorlacius H, Bourke MJ, Tham TC, Bisschops R. Curriculum for training in endoscopic mucosal resection in the colon: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2023. [PMID: 37285908 DOI: 10.1055/a-2077-0497] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Endoscopic mucosal resection (EMR) is the standard of care for the complete removal of large (≥ 10 mm) nonpedunculated colorectal polyps (LNPCPs). Increased detection of LNPCPs owing to screening colonoscopy, plus high observed rates of incomplete resection and need for surgery call for a standardized approach to training in EMR. 1 : Trainees in EMR should have achieved basic competence in diagnostic colonoscopy, < 10-mm polypectomy, pedunculated polypectomy, and common methods of gastrointestinal endoscopic hemostasis. The role of formal training courses is emphasized. Training may then commence in vivo under the direct supervision of a trainer. 2 : Endoscopy units training endoscopists in EMR should have specific processes in place to support and facilitate training. 3: A trained EMR practitioner should have mastered theoretical knowledge including how to assess an LNPCP for risk of submucosal invasion, how to interpret the potential difficulty of a particular EMR procedure, how to decide whether to remove a particular LNPCP en bloc or piecemeal, whether the risks of electrosurgical energy can be avoided for a particular LNPCP, the different devices required for EMR, management of adverse events, and interpretation of reports provided by histopathologists. 4: Trained EMR practitioners should be familiar with the patient consent process for EMR. 5: The development of endoscopic non-technical skills (ENTS) and team interaction are important for trainees in EMR. 6: Differences in recommended technique exist between EMR performed with and without electrosurgical energy. Common to both is a standardized technique based upon dynamic injection, controlled and precise snare placement, safety checks prior to the application of tissue transection (cold snare) or electrosurgical energy (hot snare), and interpretation of the post-EMR resection defect. 7: A trained EMR practitioner must be able to manage adverse events associated with EMR including intraprocedural bleeding and perforation, and post-procedural bleeding. Delayed perforation should be avoided by correct interpretation of the post-EMR defect and treatment of deep mural injury. 8: A trained EMR practitioner must be able to communicate EMR procedural findings to patients and provide them with a plan in case of adverse events after discharge and a follow-up plan. 9: A trained EMR practitioner must be able to detect and interrogate a post-endoscopic resection scar for residual or recurrent adenoma and apply treatment if necessary. 10: Prior to independent practice, a minimum of 30 EMR procedures should be performed, culminating in a trainer-guided assessment of competency using a validated assessment tool, taking account of procedural difficulty (e. g. using the SMSA polyp score). 11: Trained practitioners should log their key performance indicators (KPIs) of polypectomy during independent practice. A guide for target KPIs is provided in this document.
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Affiliation(s)
- David J Tate
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium
- Faculty of Medicine, University of Ghent, Ghent, Belgium
| | - Maria Eva Argenziano
- Clinic of Gastroenterology, Hepatology and Emergency Digestive Endoscopy, Università Politecnica delle Marche, Ancona, Italy
| | - John Anderson
- Cheltenham General Hospital, Gloucestershire Hospitals Foundation Trust, Cheltenham, UK
| | - Pradeep Bhandari
- Endoscopy Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Marek Bugajski
- Department of Gastroenterology, Luxmed Oncology, Warsaw, Poland
| | - Lobke Desomer
- AZ Delta Roeselare, University Hospital Ghent, Ghent, Belgium
| | - Steven J Heitman
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Hiroshi Kashida
- Department of Gastroenterology and Hepatology, Kindai University, Faculty of Medicine, Osaka, Japan
| | - Vladimir Kriazhov
- Endoscopy Department, Nizhny Novgorod Regional Clinical Oncology Center, Nizhny Novgorod, Russia Federation
| | - Ralph R T Lee
- The Ottawa Hospital - Civic Campus, University of Ottawa, Ottawa, Canada
| | - Ivan Lyutakov
- University Hospital Tsaritsa Yoanna-ISUL, Medical University Sofia, Sofia, Bulgaria
| | - Pedro Pimentel-Nunes
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- Surgery and Physiology Department, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Liseth Rivero-Sánchez
- Gastroenterology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | | | | | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Dundonald, Belfast, Northern Ireland
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, KU Leuven, Leuven, Belgium
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Noh SM, Hwang SW, Park SH, Yang DH, Ye BD, Park IJ, Lim SB, Byeon JS. Comparative Cost Analysis Between Endoscopic Resection and Surgery for Submucosal Colorectal Cancer. Dis Colon Rectum 2023; 66:723-732. [PMID: 35714338 DOI: 10.1097/dcr.0000000000002220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are few studies analyzing the cost of endoscopic resection and surgical resection in the treatment of submucosal colorectal cancer. OBJECTIVE The objective was to perform a detailed cost analysis of endoscopic resection and surgical resection for submucosal colorectal cancer. DESIGN This was a retrospective observational study. SETTING This study was conducted at a tertiary academic center. PATIENTS Medical records of 484 patients with submucosal colorectal cancer who underwent endoscopic resection or surgical resection between July 2003 and July 2015 were reviewed. MAIN OUTCOME MEASUREMENTS The total costs during index admission and follow-up as well as clinical outcomes between the 2 groups were compared in the whole cohort and propensity score-matched cohort. RESULTS In the propensity score-matched analysis ( n = 155 in each group), the endoscopic resection and surgical resection groups did not show significant differences in the rates of procedure-related adverse events (6.5% vs 3.9%; p = 0.304) and recurrence (0.6% vs 1.3%; p > 0.99). Readmission was more common in the endoscopic resection group (40.6% vs 11.0%; p < 0.001) because 64 (41.3%) patients underwent additional surgery for endoscopic noncurative resection. The endoscopic resection group had a lower cost during the index admission (1335.6 vs 6698.4 USD; p < 0.001), whereas the surgical resection group had a lower cost during follow-up (2488.7 vs 5035.7 USD; p < 0.001). The total cumulative cost was lower in the endoscopic resection group (6371.3 vs 9187.1 USD; p < 0.001). The same trend was observed in the whole cohort without propensity score matching. LIMITATIONS A limitation of this study was the retrospective nature of analysis. CONCLUSIONS The total cumulative cost for treatment and follow-up for submucosal colorectal cancer was lower in the endoscopic resection group, which had comparable oncologic outcomes as the surgical resection group. Endoscopic resection can be considered a cost-effective option for initial treatment for submucosal colorectal cancer. See Video Abstract at http://links.lww.com/DCR/B881 . ANLISIS COMPARATIVO DE COSTOS ENTRE LA RESECCIN ENDOSCPICA Y LA CIRUGA PARA EL CNCER COLORRECTAL SUBMUCOSO ANTECEDENTES: Existen pocos estudios que analizan el costo de la resección endoscópica y la resección quirúrgica en el tratamiento del cáncer colorrectal submucoso.OBJETIVO: El objetivo fue realizar un análisis detallado de costos tanto de la resección endoscópica y la resección quirúrgica para el cáncer colorrectal submucoso.DISEÑO: Este fue un estudio observacional retrospectivo.AJUSTE: Este estudio se realizó en un centro académico terciario.PACIENTES: Se revisaron las historias clínicas de 484 pacientes con cáncer colorrectal submucoso que fueron sometidos a resección endoscópica o resección quirúrgica entre julio de 2003 y julio de 2015.PRINCIPALES MEDICIONES DE RESULTADOS: Los costos totales durante la admisión índice y el seguimiento, así como los resultados clínicos entre los dos grupos, fueron comparados en toda la cohorte y la cohorte emparejada por puntuación de propensión.RESULTADOS: En el análisis emparejado por puntuación de propensión ( n = 155 en cada grupo), los grupos de resección endoscópica y resección quirúrgica no mostraron diferencias significativas en las tasas de eventos adversos relacionados con el procedimiento (6,5% vs 3,9%, p = 0,304) y recurrencia (0,6% vs 1,3%, p > 0,99). La readmisión fue más común en el grupo de resección endoscópica (40,6% vs 11,0%, p < 0,001) porque 64 (41,3%) pacientes fueron sometidos a una cirugía adicional para lograr la resección en aquellos casos en que la resección endoscópica no fue curativa. El grupo de resección endoscópica tuvo un costo menor durante el ingreso índice (1335.6 vs 6698.4 USD, p < 0.001), mientras que el grupo de resección quirúrgica tuvo un costo menor durante el seguimiento (2488.7 vs 5035.7 USD, p < 0.001). El costo total acumulado fue menor en el grupo de resección endoscópica (6371,3 vs 9187,1 USD, p < 0,001). La misma tendencia se observó en toda la cohorte sin emparejamiento por puntuación de propensión.LIMITACIONES: La naturaleza retrospectiva del análisis.CONCLUSIONES: El costo total acumulado para el tratamiento y seguimiento del cáncer colorrectal submucoso fue menor en el grupo de resección endoscópica, que tuvo resultados oncológicos comparables a los del grupo de resección quirúrgica. La resección endoscópica puede considerarse una opción rentable para el tratamiento inicial del cáncer colorrectal submucoso. Consulte Video Resumen en http://links.lww.com/DCR/B881 . (Traducción-Dr Osvaldo Gauto ).
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Affiliation(s)
- Soo Min Noh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung Wook Hwang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - In Ja Park
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seok-Byung Lim
- Department of Colon and Rectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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21
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Abu Arisha M, Scapa E, Wishahi E, Korytny A, Gorelik Y, Mazzawi F, Khader M, Muaalem R, Bana S, Awadie H, Bourke MJ, Klein A. Impact of margin ablation after EMR of large nonpedunculated colonic polyps in routine clinical practice. Gastrointest Endosc 2023; 97:559-567. [PMID: 36328207 DOI: 10.1016/j.gie.2022.10.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/14/2022] [Accepted: 10/23/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Owing to its simplicity, effectiveness, and safety, EMR is the preferred treatment for the majority of large (≥20 mm) nonpedunculated colonic polyps (LNPCPs); however, residual and recurrent adenomas (RRAs) encountered during surveillance constitute a major limitation. Thermal ablation of the post-EMR mucosal defect margin has been shown to be highly efficacious in reducing RRA in a randomized trial setting, but data on effectiveness in clinical practice are scarce. We aimed to determine the effectiveness of this technique for reducing RRAs in routine clinical practice. METHODS We analyzed data collected in 3 hospitals in Israel: Prospective data were available in 2 hospitals where margin thermal ablation with snare-tip soft coagulation (STSC) is routinely performed after EMR of LNPCP (TA-EMR). Only retrospective data were available from the third center, which exclusively did not perform STSC (standard EMR] [S-EMR]), during the study period. Surveillance was performed 4 to 6 months after resection. RRA was assessed endoscopically with high-definition white light and optical chromoendoscopy. The primary endpoint was RRA at first surveillance colonoscopy. RESULTS Data from 764 patients with 824 LNPCPs were analyzed. The patient and lesion characteristics were similar between the groups. Four hundred sixty-four LNPCPs were treated by TA-EMR and 360 LNPCPs by S-EMR. RRA at first surveillance colonoscopy was detected in 14 (3.6%) of lesions in the TA-EMR group compared with 96 (31.6%) in the S-EMR group (P < .001; RR = .14; 95% CI, .07-.29). Adverse events were comparable between the 2 groups. CONCLUSION TA-EMR leads to a significant reduction in post-EMR recurrence in routine clinical practice.
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Affiliation(s)
- Muhammad Abu Arisha
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel; Department of Internal Medicine D, Rambam Health Care Campus, Haifa, Israel
| | - Erez Scapa
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Efad Wishahi
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Alexander Korytny
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Yuri Gorelik
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Fares Mazzawi
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel; Department of Internal Medicine D, Rambam Health Care Campus, Haifa, Israel
| | - Majd Khader
- Department of Gastroenterology, Barzilai Medical Center, Ashkelon, Israel
| | - Rawia Muaalem
- Department of Gastroenterology, Holy Family Hospital, Nazareth, Israel
| | - Suzan Bana
- Department of Gastroenterology, Holy Family Hospital, Nazareth, Israel
| | - Halim Awadie
- Department of Gastroenterology, Holy Family Hospital, Nazareth, Israel
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia, and Westmead Clinical School, University of Sydney, New South Wales, Australia
| | - Amir Klein
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel.
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22
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Ma MX, Tate DJ, Sidhu M, Zahid S, Bourke MJ. Effect of pre-resection biopsy on detection of advanced dysplasia in large nonpedunculated colorectal polyps undergoing endoscopic mucosal resection. Endoscopy 2023; 55:267-273. [PMID: 35817086 DOI: 10.1055/a-1896-9798] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND : Pre-resection biopsy (PRB) of large nonpedunculated colorectal polyps (LNPCPs, ≥ 20 mm) is often performed before referral for endoscopic mucosal resection (EMR). How this affects the EMR procedure is unknown. METHODS : This was a retrospective analysis of a prospectively collected cohort of patients with LNPCPs referred for EMR between 2013 to 2016 at an Australian tertiary center. Outcomes were differences between PRB and EMR histology, and effects of PRB on the EMR procedure. RESULTS: Among 586 LNPCPs, lesions that underwent PRB were larger (median 35 vs. 30 mm; P < 0.007), and more commonly morphologically flat or slightly elevated (P = 0.01) compared with lesions without PRB. PRB histology was upstaged in 26.1 %, downstaged in 13.8 %, and unchanged in 60.1 % after EMR. Sensitivity of PRB was 77.2 % (95 %CI 71.1-82.4) for low grade dysplasia (LGD) and 21.2 % (95 %CI 11.5-35.1) for high grade dysplasia (HGD). Where EMR specimen showed HGD, PRB had detected LGD in 76.9 %. Where EMR specimen showed cancer, PRB had detected dysplasia only. PRB was associated with more submucosal fibrosis (P = 0.001) and intraprocedural bleeding (P = 0.03). EMR success or recurrence was not affected. CONCLUSIONS: Routine PRB of LNPCP did not reliably detect advanced histology and may have affected EMR complexity. PRB should be utilized with caution in guiding endoscopic management of LNPCPs.
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Affiliation(s)
- Michael X Ma
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Department of Gastroenterology and Hepatology, Fiona Stanley Hospital, Perth, Australia
- Department of Medicine, Midland St. John of God Hospital, Perth, Australia
| | - David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - Simmi Zahid
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
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23
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Miyazaki K, Wada Y, Okuno K, Murano T, Morine Y, Ikemoto T, Saito Y, Ikematsu H, Kinugasa Y, Shimada M, Goel A. An exosome-based liquid biopsy signature for pre-operative identification of lymph node metastasis in patients with pathological high-risk T1 colorectal cancer. Mol Cancer 2023; 22:2. [PMID: 36609320 PMCID: PMC9817247 DOI: 10.1186/s12943-022-01685-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 11/25/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND According to current guidelines, more than 70% of patients with invasive submucosal colorectal cancer (T1 CRC) undergo a radical operation with lymph node dissection, even though only ~ 10% have lymph node metastasis (LNM). Hence, there is imperative to develop biomarkers that can help robustly identify LNM-positive patients to prevent such overtreatments. Given the emerging interest in exosomal cargo as a source for biomarker development in cancer, we examined the potential of exosomal miRNAs as LNM prediction biomarkers in T1 CRC. METHODS We analyzed 200 patients with high-risk T1 CRC from two independent cohorts, including a training (n = 58) and a validation cohort (n = 142). Cell-free and exosomal RNAs from pre-operative serum were extracted, followed by quantitative reverse-transcription polymerase chain reactions for a panel of miRNAs. RESULTS A panel of four miRNAs (miR-181b, miR-193b, miR-195, and miR-411) exhibited robust ability for detecting LNM in the exosomal vs. cell-free component. We subsequently established a cell-free and exosomal combination signature, successfully validated in two independent clinical cohorts (AUC, 0.84; 95% CI 0.70-0.98). Finally, we developed a risk-stratification model by including key pathological features, which reduced the false positive rates for LNM by 76% without missing any true LNM-positive patients. CONCLUSIONS Our novel exosomal miRNA-based liquid biopsy signature robustly identifies T1 CRC patients at risk of LNM in a preoperative setting. This could be clinically transformative in reducing the significant overtreatment burden of this malignancy.
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Affiliation(s)
- Katsuki Miyazaki
- grid.410425.60000 0004 0421 8357Department of Molecular Diagnostics and Experimental Therapeutics, Beckman Research Institute of City of Hope, Biomedical Research Center, 1218 S. Fifth Avenue, Suite 2226, Monrovia, CA 91016 USA ,grid.267335.60000 0001 1092 3579Department of Surgery, Tokushima University, Tokushima, Japan
| | - Yuma Wada
- grid.410425.60000 0004 0421 8357Department of Molecular Diagnostics and Experimental Therapeutics, Beckman Research Institute of City of Hope, Biomedical Research Center, 1218 S. Fifth Avenue, Suite 2226, Monrovia, CA 91016 USA ,grid.267335.60000 0001 1092 3579Department of Surgery, Tokushima University, Tokushima, Japan
| | - Keisuke Okuno
- grid.410425.60000 0004 0421 8357Department of Molecular Diagnostics and Experimental Therapeutics, Beckman Research Institute of City of Hope, Biomedical Research Center, 1218 S. Fifth Avenue, Suite 2226, Monrovia, CA 91016 USA ,grid.265073.50000 0001 1014 9130Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tatsuro Murano
- grid.497282.2Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Chiba, Japan
| | - Yuji Morine
- grid.267335.60000 0001 1092 3579Department of Surgery, Tokushima University, Tokushima, Japan
| | - Tetsuya Ikemoto
- grid.267335.60000 0001 1092 3579Department of Surgery, Tokushima University, Tokushima, Japan
| | - Yu Saito
- grid.267335.60000 0001 1092 3579Department of Surgery, Tokushima University, Tokushima, Japan
| | - Hiroaki Ikematsu
- grid.497282.2Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Chiba, Japan
| | - Yusuke Kinugasa
- grid.265073.50000 0001 1014 9130Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mitsuo Shimada
- grid.267335.60000 0001 1092 3579Department of Surgery, Tokushima University, Tokushima, Japan
| | - Ajay Goel
- grid.410425.60000 0004 0421 8357Department of Molecular Diagnostics and Experimental Therapeutics, Beckman Research Institute of City of Hope, Biomedical Research Center, 1218 S. Fifth Avenue, Suite 2226, Monrovia, CA 91016 USA ,grid.410425.60000 0004 0421 8357City of Hope Comprehensive Cancer Center, Duarte, CA USA
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24
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Bustamante-Balén M. How to avoid overtreatment of benign colorectal lesions: Rationale for an evidence-based management. World J Gastroenterol 2022; 28:6619-6631. [PMID: 36620344 PMCID: PMC9813935 DOI: 10.3748/wjg.v28.i47.6619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/10/2022] [Accepted: 11/27/2022] [Indexed: 12/19/2022] Open
Abstract
Implementing population-based screening programs for colorectal cancer has led to an increase in the detection of large but benign histological lesions. Currently, endoscopic mucosal resection can be considered the standard technique for the removal of benign lesions of the colon due to its excellent safety profile and good clinical results. However, several studies from different geographic areas agree that many benign colon lesions are still referred for surgery. Moreover, the referral rate to surgery is not decreasing over the years, despite the theoretical improvement of endoscopic resection techniques. This article will review the leading causes for benign colorectal lesions to be referred for surgery and the influence of the endoscopist experience on the referral rate. It will also describe how to categorize a polyp as complex for resection and consider an endoscopist as an expert in endoscopic resection. And finally, we will propose a framework for the accurate and evidence-based treatment of complex benign colorectal lesions.
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Affiliation(s)
- Marco Bustamante-Balén
- Gastrointestinal Endoscopy Unit, Gastrointestinal Endoscopy Research Group, Hospital Universitari I Politècnic La Fe, Health Research Institute Hospital La Fe (IISLaFe), Valencia 46026, Spain
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25
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Gibson DJ, Sidhu M, Zanati S, Tate DJ, Mangira D, Moss A, Singh R, Hourigan LF, Raftopoulos S, Pham A, Kostos P, Kumarasinghe MP, Ruszkiewicz A, McLeod D, Brown GJE, Bourke MJ. Oncological outcomes after piecemeal endoscopic mucosal resection of large non-pedunculated colorectal polyps with covert submucosal invasive cancer. Gut 2022; 71:2481-2488. [PMID: 35256387 DOI: 10.1136/gutjnl-2020-323666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/25/2022] [Indexed: 12/08/2022]
Abstract
OBJECTIVE Management of covert submucosal invasive cancer (SMIC) discovered after piecemeal endoscopic mucosal resection (pEMR) of large (>20 mm) non-pedunculated colorectal polyps is challenging. The residual cancer risk is largely unknown. We sought to evaluate this in a large tertiary referral cohort. DESIGN Cases of covert SMIC following pEMR were identified and followed. Oncological outcomes after surgery were divided based on residual intramural cancer, lymph node metastases (LNM) or both. Risk factors for residual intramural cancer and LNM were analysed based on the original pEMR histological variables. Risk parameters were analysed with respect to low and high-risk variables for residual intramural cancer and LNM. RESULTS Among 3372 cases of large non-pedunculated colorectal polyps, 143 cases of covert SMIC (4.2%) were identified. 109 underwent surgical resection. Histological analysis of pEMR histology was available in 98 of 109 (90%) cases. 62 cases (63%) had no residual malignancy. 36 cases had residual malignancy (residual intramural cancer n=24; LNM n=5; both n=7). All cases of residual intramural cancer could be identified by a R1 histological deep margin. Cases with poor differentiation (PD) and/or lymphovascular invasion (LVI) had a high risk of LNM (12/33), with a very low risk without these criteria (<1%; 0/65). Cases at low risk for LNM with R0 deep margin have a low risk of residual intramural cancer (<1%; 0/35). CONCLUSION The majority of cases of large non-pedunculated colorectal polyps with covert SMIC following pEMR will have no residual malignancy. The risk of residual malignancy can be ascertained from three key variables: PD, LVI and R1 deep margin.
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Affiliation(s)
- Dave J Gibson
- Gastroenterology, Alfred Health, Melbourne, Victoria, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Simon Zanati
- Gastroenterology, Western Health, Footscray, Victoria, Australia
| | - David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Dileep Mangira
- Gastroenterology, Western Health, Footscray, Victoria, Australia
| | - Alan Moss
- Department of Gastroenterology, Western Hospital, Footscray, Victoria, Australia
| | - Rajvinder Singh
- Gastroenterology, Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Luke F Hourigan
- Gastroenterology, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Spiro Raftopoulos
- Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Alan Pham
- Anatomical Pathology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Phil Kostos
- Pathology, Western Health, Footscray, Victoria, Australia
| | - M Priyanthi Kumarasinghe
- Department of Anatomical Pathology, PathWest, QEII Medical Centre, Perth, Western Australia, Australia
| | | | - Duncan McLeod
- Institute of Clinical Pathology and Medical Research, Westmead Millennium Institute and Westmead Hospital, University of Sydney, Australia, Westmead Hospital, Westmead, New South Wales, Australia
| | | | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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26
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Forbes N, Gupta S, Frehlich L, Meng ZW, Ruan Y, Montori S, Chebaa BR, Dunbar KB, Heitman SJ, Feagins LA, Albéniz E, Pohl H, Bourke MJ. Clip closure to prevent adverse events after EMR of proximal large nonpedunculated colorectal polyps: meta-analysis of individual patient data from randomized controlled trials. Gastrointest Endosc 2022; 96:721-731.e2. [PMID: 35667388 DOI: 10.1016/j.gie.2022.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/18/2022] [Accepted: 05/24/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS After EMR, prophylactic clipping is often performed to prevent clinically significant post-EMR bleeding (CSPEB) and other adverse events (AEs). Prior evidence syntheses have lacked sufficient power to assess clipping in relevant subgroups or in nonbleeding AEs. We performed a meta-analysis of individual patient data (IPD) from randomized trials assessing the efficacy of clipping to prevent AEs after EMR of proximal large nonpedunculated colorectal polyps (LNPCPs) ≥20 mm. METHODS We searched EMBASE, MEDLINE, Cochrane Central Registry of Controlled Trials, and PubMed from inception to May 19, 2021. Two reviewers screened citations in duplicate. Corresponding authors of eligible studies were invited to contribute IPD. A random-effects 1-stage model was specified for estimating pooled effects, adjusting for patient sex and age and for lesion location and size, whereas a fixed-effects model was used for traditional meta-analyses. RESULTS From 3145 citations, 4 trials were included, representing 1248 patients with proximal LNPCPs. The overall rate of CSPEB was 3.5% and 9.0% in clipped and unclipped patients, respectively. IPD were available for 1150 patients, in which prophylactic clipping prevented CSPEB with an odds ratio (OR) of .31 (95% confidence interval [CI], .17-.54). Clipping was not associated with perforation or abdominal pain, with ORs of .78 (95% CI, .17-3.54) and .67 (95% CI, .20-2.22), respectively. CONCLUSIONS Prophylactic clipping is efficacious in preventing CSPEB after EMR of proximal LNPCPs. Therefore, clip closure should be considered a standard component of EMR of LNPCPs in the proximal colon.
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Affiliation(s)
- Nauzer Forbes
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Levi Frehlich
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Zhao Wu Meng
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Yibing Ruan
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cancer Epidemiology and Prevention Research, Cancer Control Alberta, Alberta Health Services, Calgary, Alberta, Canada
| | - Sheyla Montori
- Gastrointestinal Endoscopy Research Unit, Navarrabiomed Biomedical Research Center, UPNA, IdiSNA, Pamplona, Spain
| | - Benjamin R Chebaa
- Department of Medicine, Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
| | - Kerry B Dunbar
- Department of Medicine, VA North Texas Healthcare System, Dallas, Texas, USA; Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Steven J Heitman
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Linda A Feagins
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Eduardo Albéniz
- Gastrointestinal Endoscopy Research Unit, Navarrabiomed Biomedical Research Center, UPNA, IdiSNA, Pamplona, Spain; Endoscopy Unit, Gastroenterology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Heiko Pohl
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA; Department of Gastroenterology, VA Medical Center, White River Junction, Vermont, USA; Department of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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27
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Komanduri S, Dominitz JA, Rabeneck L, Kahi C, Ladabaum U, Imperiale TF, Byrne MF, Lee JK, Lieberman D, Wang AY, Sultan S, Shaukat A, Pohl H, Muthusamy VR. AGA White Paper: Challenges and Gaps in Innovation for the Performance of Colonoscopy for Screening and Surveillance of Colorectal Cancer. Clin Gastroenterol Hepatol 2022; 20:2198-2209.e3. [PMID: 35688352 DOI: 10.1016/j.cgh.2022.03.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 02/23/2022] [Accepted: 03/17/2022] [Indexed: 02/07/2023]
Abstract
In 2018, the American Gastroenterological Association's Center for GI Innovation and Technology convened a consensus conference, entitled "Colorectal Cancer Screening and Surveillance: Role of Emerging Technology and Innovation to Improve Outcomes." The conference participants, which included more than 60 experts in colorectal cancer, considered recent improvements in colorectal cancer screening rates and polyp detection, persistent barriers to colonoscopy uptake, and opportunities for performance improvement and innovation. This white paper originates from that conference. It aims to summarize current patient- and physician-centered gaps and challenges in colonoscopy, diagnostic and therapeutic challenges affecting colonoscopy uptake, and the potential use of emerging technologies and quality metrics to improve patient outcomes.
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Affiliation(s)
- Srinadh Komanduri
- Department of Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Jason A Dominitz
- Veterans Affairs Puget Sound Health Care System and the Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Linda Rabeneck
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Charles Kahi
- Indiana University School of Medicine, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Thomas F Imperiale
- Department of Medicine, Indiana University School of Medicine, the Regenstrief Institute, the Simon Cancer Center, and the Center for Innovation at Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
| | - Michael F Byrne
- Division of Gastroenterology, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey K Lee
- Collaborative Health Outcomes Research in Digestive Diseases (CHORD) Group, Kaiser Permanente Division of Research, Kaiser Permanente San Francisco, San Francisco, California
| | - David Lieberman
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia
| | - Shahnaz Sultan
- Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Aasma Shaukat
- Division of Gastroenterology, Minneapolis Veterans Affairs Health Care System and Department of Medicine, School of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Heiko Pohl
- Veterans Affairs Medical Center White River Junction, Vermont; Dartmouth Geisel School of Medicine, Hanover, New Hampshire
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, University of California Los Angeles, Los Angeles, California.
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28
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Buskermolen M, Naber SK, Toes-Zoutendijk E, van der Meulen MP, van Grevenstein WMU, van Leerdam ME, Spaander MCW, Lansdorp-Vogelaar I. Impact of surgical versus endoscopic management of complex nonmalignant polyps in a colorectal cancer screening program. Endoscopy 2022; 54:871-880. [PMID: 35130576 DOI: 10.1055/a-1726-9144] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND When complex nonmalignant polyps are detected in colorectal cancer (CRC) screening programs, patients may be referred directly to surgery or may first undergo additional endoscopy for attempted endoscopic removal by an expert. We compared the impact of both strategies on screening effectiveness and costs. METHODS We used MISCAN-Colon to simulate the Dutch screening program, and projected CRC deaths prevented, quality-adjusted life-years (QALYs) gained, and costs for two scenarios: 1) surgery for all complex nonmalignant polyps; 2) attempted removal by an expert endoscopist first. We made the following assumptions: 3.9 % of screen-detected large nonmalignant polyps were complex; associated surgery mortality was 0.7 %; the rate of successful removal by an expert was 87 %, with 0.11 % mortality. RESULTS The screening program was estimated to prevent 11.2 CRC cases (-16.7 %) and 10.1 CRC deaths (-27.1 %), resulting in 32.9 QALYs gained (+ 17.2 %) per 1000 simulated individuals over their lifetimes compared with no screening. The program would also result in 2.1 surgeries for complex nonmalignant polyps with 0.015 associated deaths per 1000 individuals. If, instead, these patients were referred to an expert endoscopist first, only 0.2 patients required surgery, reducing associated deaths by 0.013 at the expense of 0.003 extra colonoscopy deaths. Compared with direct referral to surgery, referral to an expert endoscopist gained 0.2 QALYs and saved €12 500 per 1000 individuals in the target population. CONCLUSION Referring patients with complex polyps to an expert endoscopist first reduced some surgery-related deaths while substantially improving cost-effectiveness of the screening program.
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Affiliation(s)
- Maaike Buskermolen
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Steffie K Naber
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Esther Toes-Zoutendijk
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Miriam P van der Meulen
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Monique E van Leerdam
- Department of Gastroenterology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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29
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Auriemma F, Sferrazza S, Bianchetti M, Savarese MF, Lamonaca L, Paduano D, Piazza N, Giuffrida E, Mete LS, Tucci A, Milluzzo SM, Iannelli C, Repici A, Mangiavillano B. From advanced diagnosis to advanced resection in early neoplastic colorectal lesions: Never-ending and trending topics in the 2020s. World J Gastrointest Surg 2022; 14:632-655. [PMID: 36158280 PMCID: PMC9353749 DOI: 10.4240/wjgs.v14.i7.632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/02/2021] [Accepted: 06/20/2022] [Indexed: 02/06/2023] Open
Abstract
Colonoscopy represents the most widespread and effective tool for the prevention and treatment of early stage preneoplastic and neoplastic lesions in the panorama of cancer screening. In the world there are different approaches to the topic of colorectal cancer prevention and screening: different starting ages (45-50 years); different initial screening tools such as fecal occult blood with immunohistochemical or immune-enzymatic tests; recto-sigmoidoscopy; and colonoscopy. The key aspects of this scenario are composed of a proper bowel preparation that ensures a valid diagnostic examination, experienced endoscopist in detection of preneoplastic and early neoplastic lesions and open-minded to upcoming artificial intelligence-aided examination, knowledge in the field of resection of these lesions (from cold-snaring, through endoscopic mucosal resection and endoscopic submucosal dissection, up to advanced tools), and management of complications.
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Affiliation(s)
- Francesco Auriemma
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza 21053, Italy
| | - Sandro Sferrazza
- Gastroenterology and Endoscopy Unit, Santa Chiara Hospital, Trento 38014, Italy
| | - Mario Bianchetti
- Digestive Endoscopy Unit, San Giuseppe Hospital - Multimedica, Milan 20123, Italy
| | - Maria Flavia Savarese
- Department of Gastroenterology and Gastrointestinal Endoscopy, General Hospital, Sanremo 18038, Italy
| | - Laura Lamonaca
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza 21053, Italy
| | - Danilo Paduano
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza 21053, Italy
| | - Nicole Piazza
- Gastroenterology Unit, IRCCS Policlinico San Donato, San Donato Milanese; Department of Biomedical Sciences for Health, University of Milan, Milan 20122, Italy
| | - Enrica Giuffrida
- Gastroenterology and Hepatology Unit, A.O.U. Policlinico “G. Giaccone", Palermo 90127, Italy
| | - Lupe Sanchez Mete
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Regina Elena National Cancer Institute, Rome 00144, Italy
| | - Alessandra Tucci
- Department of Gastroenterology, Molinette Hospital, Città della salute e della Scienza di Torino, Turin 10126, Italy
| | | | - Chiara Iannelli
- Department of Health Sciences, Magna Graecia University, Catanzaro 88100, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit and Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano 20089, Italy
| | - Benedetto Mangiavillano
- Biomedical Science, Hunimed, Pieve Emanuele 20090, Italy
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza, Varese 21053, Italy
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30
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Hao XW, Li P, Wang YJ, Ji M, Zhang ST, Shi HY. Predictors for malignant potential and deep submucosal invasion in colorectal laterally spreading tumors. World J Gastrointest Oncol 2022; 14:1337-1347. [PMID: 36051097 PMCID: PMC9305571 DOI: 10.4251/wjgo.v14.i7.1337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/24/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Colorectal laterally spreading tumors (LSTs) with malignant potential require en bloc resection by endoscopic submucosal dissection (ESD), but lesions with deep submucosal invasion (SMI) are endoscopically unresectable.
AIM To investigate the factors associated with high-grade dysplasia (HGD)/carcinoma and deep SMI in colorectal LSTs.
METHODS The endoscopic and histological results of consecutive patients who underwent ESD for colorectal LSTs in our hospital from June 2013 to March 2019 were retrospectively analyzed. The characteristics of LST subtypes were compared. Risk factors for HGD/carcinoma and deep SMI (invasion depth ≥ 1000 μm) were determined using multivariate logistic regression.
RESULTS A total of 323 patients with 341 colorectal LSTs were enrolled. Among the four subtypes, non-granular pseudodepressed (NG-PD) LSTs (85.5%) had the highest rate of HGD/carcinoma, followed by the granular nodular mixed (G-NM) (77.0%), granular homogenous (29.5%), and non-granular flat elevated (24.2%) subtypes. Deep SMI occurred commonly in NG-PD LSTs (12.9%). In the adjusted multivariate analysis, NG-PD [odds ratio (OR) = 16.8, P < 0.001) and G-NM (OR = 7.8, P < 0.001) subtypes, size ≥ 2 cm (OR = 2.2, P = 0.005), and positive non-lifting sign (OR = 3.3, P = 0.024) were independently associated with HGD/carcinoma. The NG-PD subtype (OR = 13.3, P < 0.001) and rectosigmoid location (OR = 8.7, P = 0.007) were independent risk factors for deep SMI.
CONCLUSION Because of their increased risk for malignancy, it is highly recommended that NG-PD and G-NM LSTs are removed en bloc through ESD. Given their substantial risk for deep SMI, surgery needs to be considered for NG-PD LSTs located in the rectosigmoid, especially those with positive non-lifting signs.
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Affiliation(s)
- Xiao-Wen Hao
- National Clinical Research Centre for Digestive Disease, Beijing Digestive Disease Centre, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Peng Li
- National Clinical Research Centre for Digestive Disease, Beijing Digestive Disease Centre, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Yong-Jun Wang
- National Clinical Research Centre for Digestive Disease, Beijing Digestive Disease Centre, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Ming Ji
- National Clinical Research Centre for Digestive Disease, Beijing Digestive Disease Centre, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Shu-Tian Zhang
- National Clinical Research Centre for Digestive Disease, Beijing Digestive Disease Centre, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Hai-Yun Shi
- National Clinical Research Centre for Digestive Disease, Beijing Digestive Disease Centre, Beijing Key Laboratory for Precancerous Lesion of Digestive Disease, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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31
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Cronin O, Sidhu M, Shahidi N, Gupta S, O'Sullivan T, Whitfield A, Wang H, Kumar P, Hourigan LF, Byth K, Burgess NG, Bourke MJ. Comparison of the morphology and histopathology of large nonpedunculated colorectal polyps in the rectum and colon: implications for endoscopic treatment. Gastrointest Endosc 2022; 96:118-124. [PMID: 35219724 DOI: 10.1016/j.gie.2022.02.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/15/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The risk of cancer in large nonpedunculated colorectal polyps ≥20 mm (LNPCPs) in the rectum relative to the remainder of the colon is unknown. We aimed to describe differences between rectal and colonic LNPCPs to better inform treatment decisions. METHODS Patients with LNPCPs referred to tertiary centers for endoscopic resection within a prospective, multicenter, observational cohort were evaluated. Data recorded were participant demographics, LNPCP location, morphology, resection modality, and histopathologic data. Multiple logistic regression analysis was used to identify those variables independently associated with rectal versus nonrectal location in the colon. RESULTS Patients with LNPCPs referred for endoscopic resection between July 2008 and July 2021 were included. Rectal LNPCPs (n = 618) were larger (median size, 40 mm vs 30 mm; P < .001) and more likely to be granular (79% vs 50%, P < .001) with a nodular component (53% vs 17%, P < .001) compared with nonrectal LNPCPs (n = 2787). Rectal LNPCPs were more likely to have tubulovillous histopathology (72% vs 47%, P < .001) and contain cancer (15% vs 6%, P < .001). After adjusting for the other features independently associated with location, cancer was more common in the rectum compared with the colon (odds ratio, 1.77; 95% confidence interval, 1.25-2.53). CONCLUSIONS This study suggests that compared with LNPCPs in the rest of the colon, rectal LNPCPs are more likely to be larger and contain more advanced pathology. These findings have implications for curative endoscopic resection techniques particularly where early cancer is present. (Clinical trial registration numbers: NCT01368289 and NCT02000141.).
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Affiliation(s)
- Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia; Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, School of Medicine, University of Queensland, Brisbane, Queensland, Australia; Gallipoli Medical Research Foundation, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Timothy O'Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Hunter Wang
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Puja Kumar
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, School of Medicine, University of Queensland, Brisbane, Queensland, Australia; Gallipoli Medical Research Foundation, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Karen Byth
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Tidehag V, Törnqvist B, Pekkari K, Marsk R. Endoscopic submucosal dissection for removal of large colorectal neoplasias in an outpatient setting: a single-center series of 660 procedures in Sweden. Gastrointest Endosc 2022; 96:101-107. [PMID: 35217016 DOI: 10.1016/j.gie.2022.02.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/15/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) is a technique developed in Japan for the removal of large lesions in the GI tract. Because of the complexity of the technique, implementation in Western health care has been slow. An ESD procedure is usually followed by hospital admission. Our aim was to investigate if ESD of colorectal lesions can be performed in an outpatient setting. METHODS Six hundred sixty colorectal ESD procedures between 2014 and 2020 were evaluated retrospectively. All patients referred to the unit with an early colorectal neoplasm >20 mm without signs of deep invasion were considered eligible for an ESD procedure. RESULTS Of 660 lesions, 323 (48.9%) were localized in the proximal colon, 102 (15.5%) in the distal colon, and 235 (35.6%) in the rectum. Median lesion size was 38 mm (interquartile range, 30-50) and median procedure duration 70 minutes (interquartile range, 45-115). En-bloc resection was achieved in 620 cases (93.9%). R0 resection was achieved in 492 en-bloc resections (79.4%), whereas the number of Rx and R1 resections was 124 (20.0%) and 4 (.6%), respectively. Low-grade dysplasia was found in 473 cases (71.7%), high-grade dysplasia in 144 (21.8%), and adenocarcinoma in 34 (5.1%). Six hundred twelve procedures (92.7%) were scheduled as outpatient, and 33 of these underwent unplanned admission. Forty-eight cases (7.3%) were planned as inpatient procedures. The rate of full wall perforation was 38 (5.8%), in which 35 (92.1%) were managed endoscopically and 3 patients (7.9%) required emergency surgery. Forty-six patients (7.0%) sought medical attention within 30 days because of bleeding (21 [3.2%]), abdominal tenderness (16 [2.4%]), and other reasons (9 [1.4%]). Twenty-four of these patients were admitted for observation for a median of 2 days (range, 1-7). Ten of these patients were treated with antibiotics, and 6 patients required blood transfusion. None required additional surgery. CONCLUSIONS ESD of colorectal lesions can be safely performed in an outpatient setting in a well-selected patient.
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Affiliation(s)
- Viktor Tidehag
- Department of Surgery and Urology, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Björn Törnqvist
- Department of Surgery and Urology, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Klas Pekkari
- Department of Surgery and Urology, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Richard Marsk
- Department of Surgery and Urology, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
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Motz VL, Lester C, Moyer MT, Maranki JL, Levenick JM. Hybrid argon plasma coagulation-assisted endoscopic mucosal resection for large sessile colon polyps to reduce local recurrence: a prospective pilot study. Endoscopy 2022; 54:580-584. [PMID: 34905795 PMCID: PMC9132731 DOI: 10.1055/a-1677-3954] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 08/04/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) of large, sessile colon polyps often results in incomplete resection with subsequent recurrence. The aim of this prospective pilot study was to evaluate the efficacy and safety of a novel technique, hybrid argon plasma coagulation-assisted EMR (hAPC-EMR), to remove large, sessile polyps. METHODS 40 eligible patients underwent hAPC-EMR for the removal of one or more nonpedunculated colon polyps ≥ 20 mm. Participants were contacted 30 days post-procedure to assess for adverse events and were recommended to return for a surveillance colonoscopy at 6 months to assess for local recurrence. RESULTS At the time writing, 32 patients with 35 polyps (median size 27 mm; interquartile range 14.5 mm) resected by hAPC-EMR had undergone the 6-month follow-up colonoscopy. Recurrence rate was 0 % (95 % confidence interval [CI] 0-0) at follow-up. Post-polypectomy bleeding was experienced by three patients (7.5 %; 95 %CI 0.00-0.15), and no patients developed post-polypectomy syndrome. CONCLUSION These preliminary results showed 0 % local recurrence rate at 6 months and demonstrated the safety profile of hAPC-EMR. A large, randomized, controlled trial is required to confirm these results.
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Affiliation(s)
- Victoria L. Motz
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania, United States
| | - Courtney Lester
- Division of Gastroenterology and Hepatology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
| | - Matthew T. Moyer
- Division of Gastroenterology and Hepatology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
| | - Jennifer L. Maranki
- Division of Gastroenterology and Hepatology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
| | - John M. Levenick
- Division of Gastroenterology and Hepatology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
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Alam A, Ma C, Jiang SF, Jensen CD, Webb KH, Boparai ES, Jue TL, Munroe CA, Gupta S, Fox J, Hamerski CM, Velayos FS, Corley DA, Lee JK. Declining Colectomy Rates for Nonmalignant Colorectal Polyps in a Large, Ethnically Diverse, Community-Based Population. Clin Transl Gastroenterol 2022; 13:e00477. [PMID: 35347095 PMCID: PMC9132519 DOI: 10.14309/ctg.0000000000000477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/09/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Despite studies showing improved safety, efficacy, and cost-effectiveness of endoscopic resection for nonmalignant colorectal polyps, colectomy rates for nonmalignant colorectal polyps have been increasing in the United States and Europe. Given this alarming trend, we aimed to investigate whether colectomy rates for nonmalignant colorectal polyps are increasing or declining in a large, integrated, community-based healthcare system with access to advanced endoscopic resection procedures. METHODS We identified all individuals aged 50-85 years who underwent a colonoscopy between 2008 and 2018 and were diagnosed with a nonmalignant colorectal polyp(s) at the Kaiser Permanente Northern California integrated healthcare system. Among these individuals, we identified those who underwent a colectomy for nonmalignant colorectal polyps within 12 months after the colonoscopy. We calculated annual colectomy rates for nonmalignant colorectal polyps and stratified rates by age, sex, and race and ethnicity. Changes in rates over time were tested by the Cochran-Armitage test for a linear trend. RESULTS Among 229,730 patients who were diagnosed with nonmalignant colorectal polyps between 2008 and 2018, 1,611 patients underwent a colectomy. Colectomy rates for nonmalignant colorectal polyps decreased significantly from 125 per 10,000 patients with nonmalignant polyps in 2008 to 12 per 10,000 patients with nonmalignant polyps in 2018 (P < 0.001 for trend). When stratified by age, sex, and race and ethnicity, colectomy rates for nonmalignant colorectal polyps also significantly declined from 2008 to 2018. DISCUSSION In a large, ethnically diverse, community-based population in the United States, we found that colectomy rates for nonmalignant colorectal polyps declined significantly over the past decade likely because of the establishment of advanced endoscopy centers, improved care coordination, and an organized colorectal cancer screening program.
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Affiliation(s)
- Asim Alam
- Internal Medicine/Preventive Medicine Residency Program, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
| | - Christopher Ma
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sheng-Fang Jiang
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA;
| | - Christopher D. Jensen
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA;
| | - Kenneth H. Webb
- University of California, Berkeley, School of Public Health and Haas School of Business, Berkeley, California, USA;
| | - Eshandeep S. Boparai
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
| | - Terry L. Jue
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA;
| | - Craig A. Munroe
- Division of Gastroenterology, University of California San Francisco, San Francisco, California, USA;
| | - Suraj Gupta
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
| | - Jeffrey Fox
- Department of Gastroenterology, Kaiser Permanente San Rafael Medical Center, San Rafael, California, USA.
| | - Christopher M. Hamerski
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
| | - Fernando S. Velayos
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
| | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA;
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
| | - Jeffrey K. Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA;
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
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Yang D, Draganov PV, King W, Liu N, Sarheed A, Bhat A, Jiang P, Ladna M, Ruiz NC, Wilson J, Gorrepati VS, Pohl H. Margin marking before colorectal endoscopic mucosal resection and its impact on neoplasia recurrence (with video). Gastrointest Endosc 2022; 95:956-965. [PMID: 34861250 DOI: 10.1016/j.gie.2021.11.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 11/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Ablation of resection margins after EMR of large nonpedunculated colorectal polyps decreases recurrence. Margin marking before EMR (EMR-MM) may represent an alternative method to achieve a healthy resection margin. We aimed to determine the efficacy of EMR-MM in reducing neoplasia recurrence. METHODS We conducted a single-center historical control study of EMR cases (EMR-MM vs conventional EMR) for nonpedunculated polyps ≥20 mm between 2016 and 2021. For EMR-MM, cautery marks were placed along the lateral margins of the polyp with the snare tip. EMR was then performed to include resection of the healthy mucosa containing the marks. We compared recurrence at surveillance colonoscopy after EMR-MM versus historical control subjects. Multivariable logistic regression was performed to identify factors associated with recurrence. RESULTS Two hundred ten patients with 210 polyps (median size, 30 mm; interquartile range: 25-40) underwent EMR-MM (n = 74) or conventional EMR (n = 136). Patient and lesion characteristics were similar between the groups. At a median follow-up of 6 months, the recurrence rate was lower with EMR-MM (6/74; 8%) compared with historical control subjects (39/136; 29%) (P < .001). EMR-MM was not associated with an increased rate of adverse events. On multivariable analysis, EMR-MM remained the strongest predictor of recurrence (odds ratio, .20; 95% confidence interval, .13-.64; P = .003) aside from polyp size (odds ratio, 2.81; 95% confidence interval, 1.35-6.01; P = .008). CONCLUSIONS In this single-center historical control study, EMR-MM of large nonpedunculated colorectal polyps reduced the recurrence risk by 80% when compared with conventional EMR. This simple technique may provide an alternative to margin ablation.
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Affiliation(s)
- Dennis Yang
- Center of Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - William King
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Nanlong Liu
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Ahmed Sarheed
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Adnan Bhat
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Peter Jiang
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Michael Ladna
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Nicole C Ruiz
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jake Wilson
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | | | - Heiko Pohl
- Department of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; Department of Gastroenterology, Veterans Administration Medical Center, White River Junction, Vermont, USA
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Hayat M, Azeem N, Bilal M. Colon Polypectomy with Endoscopic Submucosal Dissection and Endoscopic Full-Thickness Resection. Gastrointest Endosc Clin N Am 2022; 32:277-298. [PMID: 35361336 DOI: 10.1016/j.giec.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic resection has become the gold standard for the management of most of the large colorectal polyps. Various endoscopic resection techniques include endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and endoscopic full-thickness resection (EFTR). ESD is a minimally invasive method for the resection of advanced lesions in the gastrointestinal (GI) tract to achieve en-bloc resection. While, EFTR is more commonly used in lesions with suspected deeper submucosal invasion, lesions originating from muscularis propria, or those with advanced fibrosis. This article reviews the indications, technique, and adverse events for use of ESD and EFTR in the colon.
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Affiliation(s)
- Maham Hayat
- Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, 800 Stanton L Young Boulevard, Oklahoma City, OK 73104, USA
| | - Nabeel Azeem
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN 55455, USA
| | - Mohammad Bilal
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN 55455, USA; Advanced Endoscopy, Division of Gastroenterology & Hepatology, Minneapolis Veterans Affairs Medical Center, 1 Veterans Drive, Minneapolis, MN 55417, USA.
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Kwok K, Tran T, Lew D. Polypectomy for Large Polyps with Endoscopic Mucosal Resection. Gastrointest Endosc Clin N Am 2022; 32:259-276. [PMID: 35361335 DOI: 10.1016/j.giec.2021.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Beginning in 1955, when the saline injection was first described to prevent transmural injury during polyp fulguration, endoscopic mucosal resection (EMR) has grown exponentially, both in scope and in practice. Because EMR is an organ-preserving technique even for large polyps, this allows for comparable outcomes to surgery, but substantially improved cost savings and significantly reduced morbidity and mortality. To achieve this, however, one must master the 4 fundamental components that are critical to the success of EMR- time, team, tools, and technique. This article aims to provide a compendium of state of the art updates within the field of endoluminal resection.
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Affiliation(s)
- Karl Kwok
- Interventional Endoscopy, Division of Gastroenterology, Kaiser Permanente, Los Angeles Medical Center, 1526 North Edgemont Street, 7th Floor, Los Angeles, CA 90027, USA.
| | - Tri Tran
- Department of Medicine, Kaiser Permanente, Los Angeles Medical Center, 4867 W Sunset Boulevard, Los Angeles, CA 90027, USA
| | - Daniel Lew
- Division of Gastroenterology, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
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Sidhu M, Shahidi N, Vosko S, van Hattem WA, Tate DJ, Bourke MJ. Incremental benefit of dye-based chromoendoscopy to predict the risk of submucosal invasive cancer in large nonpedunculated colorectal polyps. Gastrointest Endosc 2022; 95:527-534.e2. [PMID: 34875258 DOI: 10.1016/j.gie.2021.11.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 11/13/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Detailed lesion assessment of large nonpedunculated colorectal polyps (LNPCPs; ≥20 mm) can help predict the risk of submucosal invasive cancer (SMIC). Traditionally this has required the use of dye-based chromoendoscopy (DBC). We sought to assess the accuracy and incremental benefit of DBC in addition to high-definition white-light imaging (HDWLI) and virtual chromoendoscopy (VCE) for the prediction of SMIC within LNPCPs. METHODS A prospective observational study of consecutive LNPCPs at a single tertiary referral center was performed. Before resection all lesions were assessed for the presence of a demarcated area (DA), defined as an area of disordered pit or microvascular pattern, by 2 trained endoscopists before and after DBC. Diagnostic performance characteristics were calculated with histology as the reference criterion standard, and overall agreement was calculated using the κ statistic. RESULTS Over 39 months to March 2021, 400 consecutive LNPCPs (median lesion size, 35 mm; interquartile range, 25-45) were analyzed. The overall rate of SMIC was 6.5%. Presence of a DA had an accuracy of 91% (95% confidence interval, 87.7-93.5) for SMIC, independent of the use of DBC. The rate of interobserver agreement for presence of a DA using HDWLI + VCE was very high (κ = .96) with no benefit gained by the addition of DBC. CONCLUSIONS The use of HDWLI and VCE is likely to be adequate for lesion assessment for the prediction of SMIC among LNPCPs. Further, the absence of a DA is strongly predictive for the absence of SMIC, independent to the use of DBC. (Clinical trial registration number: NCT03506321.).
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Affiliation(s)
- Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School, The University of Sydney, Sydney, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School, The University of Sydney, Sydney, Australia; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - David J Tate
- Westmead Clinical School, The University of Sydney, Sydney, Australia; Department of Gastroenterology and Hepatology, University Hospital of Gent, Gent, Belgium
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School, The University of Sydney, Sydney, Australia
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Outcomes of Deep Mural Injury After Endoscopic Resection: An International Cohort of 3717 Large Non-Pedunculated Colorectal Polyps. Clin Gastroenterol Hepatol 2022; 20:e139-e147. [PMID: 33422686 DOI: 10.1016/j.cgh.2021.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/31/2020] [Accepted: 01/05/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although perforation is the most feared adverse event associated with endoscopic mucosal resection (EMR), limited data exists concerning its management. Therefore, we sought to evaluate the short- and long-term outcomes of intra-procedural deep mural injury (DMI) in an international multi-center observational cohort of large (≥20 mm) non-pedunculated colorectal polyps (LNPCPs). METHODS Consecutive patients who underwent EMR for a LNPCP ≥20 mm were evaluated. Significant DMI (S-DMI) was defined as Sydney DMI Classification type III (muscularis propria injury, target sign) or type IV/V (perforation without or with contamination, respectively). The primary outcome was successful S-DMI defect closure. Secondary outcomes included technical success (removal of all visible polypoid tissue during index EMR), surgical referral and recurrence at first surveillance colonscopy (SC1). RESULTS Between July 2008 to May 2020, 3717 LNPCPs underwent EMR. Median lesion size was 35mm (interquartile range (IQR) 25 to 45mm). Significant DMI was identified in 101 cases (2.7%), with successful defect closure in 98 (97.0%) using a median of 4 through-the-scope clips (TTSCs; IQR 3 to 6 TTSCs). Three (3.0%) patients underwent S-DMI-related urgent surgery. Technical success was achieved in 94 (93.1%) patients, with 46 (45.5%) admitted to hospital (median duration 1 day; IQR 1 to 2 days). Comparing LNPCPs with and without S-DMI, no differences in technical success (94 (93.1%) vs 3316 (91.7%); P = .62) or SC1 recurrence (12 (20.0%) vs 363 (13.6%); P = .15) were identified. CONCLUSIONS Significant DMI is readily managed endoscopically and does not appear to affect technical success or recurrence.
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Mann R, Gajendran M, Umapathy C, Perisetti A, Goyal H, Saligram S, Echavarria J. Endoscopic Management of Complex Colorectal Polyps: Current Insights and Future Trends. Front Med (Lausanne) 2022; 8:728704. [PMID: 35127735 PMCID: PMC8811151 DOI: 10.3389/fmed.2021.728704] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/27/2021] [Indexed: 12/16/2022] Open
Abstract
Most colorectal cancers arise from adenomatous polyps and sessile serrated lesions. Screening colonoscopy and therapeutic polypectomy can potentially reduce colorectal cancer burden by early detection and removal of these polyps, thus decreasing colorectal cancer incidence and mortality. Most endoscopists are skilled in detecting and removing the vast majority of polyps endoscopically during a routine colonoscopy. Polyps can be considered “complex” based on size, location, morphology, underlying scar tissue, which are not amenable to removal by conventional endoscopic polypectomy techniques. They are technically more challenging to resect and carry an increased risk of complications. Most of these polyps were used to be managed by surgical intervention in the past. Rapid advancement in endoscopic resection techniques has led to a decreasing role of surgery in managing these complex polyps. These endoscopic resection techniques do require an expert in the field and advanced equipment to perform the procedure. In this review, we discuss various advanced endoscopic techniques for the management of complex polyps.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA, United States
- *Correspondence: Rupinder Mann
| | - Mahesh Gajendran
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Chandraprakash Umapathy
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR, United States
- Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Health, Fort Wayne, IN, United States
| | - Hemant Goyal
- The Wright Center for Graduate Medical Education, Scranton, PA, United States
| | - Shreyas Saligram
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Juan Echavarria
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
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Abstract
OBJECTIVES Endoscopic mucosal resection (EMR) for removal of large polyps is well established in adults. EMR technique in the pediatric population is less utilized due to lower incidence of large intestinal polyps in pediatric patients and limited EMR training for pediatric gastroenterologists. The aim of this study is to retrospectively review safety and efficacy of pediatric EMR cases at two large, tertiary referral centers with adult and pediatric EMR expertise. METHODS A retrospective chart review was conducted at Cedars-Sinai Medical Center and Cincinnati Children's Hospital Medical Center from January 2012 to May 2021. Demographic, clinical, technical and follow up data were collected for patients <18 years of age who underwent EMR during the study period. RESULTS Fifteen pediatric EMR procedures were identified in 11 patients (five male, six female) during the study period. Indication was most frequently rectal bleeding. Polyp size removed ranged from 9 to 60 mm and pathology was consistent with juvenile inflammatory polyps in six patients. Technical success was achieved in 14 of 15 (93%) of EMRs with clinical success (desired clinical outcome) in all 13 procedures with clinical follow-up. There were no adverse events. CONCLUSIONS This study identifies a case series of pediatric patients who underwent EMR at two tertiary care centers. This series demonstrates successful EMR in children and shows a high technical and clinical success rate with a low complication rate. More investigation into EMR in pediatric patients is necessary, and its use should be isolated to centers with endoscopists with specific experience in EMR techniques.
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Valori R. Real-time video consultation during endoscopy: very welcome but plenty of questions! Endosc Int Open 2021; 9:E1863-E1864. [PMID: 34917451 PMCID: PMC8670995 DOI: 10.1055/a-1613-5089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Management of the colonic polyps referred for surgery: an opportunity for improvement. Surg Endosc 2021; 36:5392-5397. [PMID: 34750703 DOI: 10.1007/s00464-021-08858-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/21/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To examine local practice for non-malignant polyps and to calculate morbidity and mortality associated with bowel resection for this indication. METHODS This retrospective cohort study was conducted by reviewing our local gastrointestinal pathology database over a five-year period to identify colonic resections performed for benign polyps. Using search terms "polyp" and "adenoma," 272 cases were identified. Exclusion criteria included: cancer diagnosis, emergency surgeries, multiple resections, and subtotal colectomies for polyposis. 106 patients were included in the study. Primary outcome was perioperative mortality. Secondary outcomes included patient morbidity, characteristics of polyps requiring surgery, and the number of patients referred for a second endoscopic opinion prior to proceeding with surgery. RESULTS 64 male and 42 female patients with a mean age of 65.3 years (± 8.6 years) underwent colon resection for benign polyps. The mean polyp size was 32.7 mm (± 19.5 mm). 30 patients (28.6%) had polyps equal to or less than 2 cm. Most of the polyps described were sessile (n = 55, 51.9%) and located in the right colon (n = 84, 79.3%). Endoscopic resection was attempted in 31 patients (29.2%), and five cases (4.7%) were referred for a second endoscopic opinion prior to proceeding with surgery. Endoscopists incorrectly felt that polyps were malignant in 62 cases (58.5%). Using Clavien-Dindo classification, most patients had no complications n = 36 (34.0%) or minor complications n = 41 (38.7%). Twelve patients (11.3%) had complications that required antibiotics, blood transfusions, or total parental nutrition. Nine patients (8.5%) required surgical or endoscopic management. Six patients (5.7%) required ICU admission. Mortality rate was 1.9% (n = 2). CONCLUSION Surgery for benign colonic polyps is associated with significant morbidity and mortality. These findings reveal a gap in endoscopic management of benign colonic polyps.
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Hoffman A, Atreya R, Rath T, Neurath MF. Current Endoscopic Resection Techniques for Gastrointestinal Lesions: Endoscopic Mucosal Resection, Submucosal Dissection, and Full-Thickness Resection. Visc Med 2021; 37:358-371. [PMID: 34722719 DOI: 10.1159/000515354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/15/2021] [Indexed: 12/12/2022] Open
Abstract
Background Endoscopic resection of dysplastic lesions in early stages of cancer reduces mortality rates and is recommended by many national guidelines throughout the world. Snare polypectomy and endoscopic mucosal resection (EMR) are established techniques of polyp removal. The advantages of these methods are their relatively short procedure times and acceptable complication rates. The latter include delayed bleeding in 0.9% and a perforation risk of 0.4-1.3%, depending on the size and location of the resected lesion. EMR is a recent modification of endoscopic resection. A limited number of studies suggest that larger lesions can be removed en bloc with low complication rates and short procedure times. Novel techniques such as endoscopic submucosal dissection (ESD) are used to enhance en bloc resection rates for larger, flat, or sessile lesions. Endoscopic full-thickness resection (EFTR) is employed for non-lifting lesions or those not easily amenable to resection. Procedures such as ESD or EFTR are emerging standards for lesions inaccessible to EMR techniques. Summary Endoscopic treatment is now regarded as first-line therapy for benign lesions. Key Message Endoscopic resection of dysplastic lesions or early stages of cancer is recommended. A plethora of different techniques can be used dependent on the lesions.
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Affiliation(s)
- Arthur Hoffman
- Department of Internal Medicine III, Aschaffenburg-Alzenau Clinic, Aschaffenburg, Germany
| | - Raja Atreya
- First Department of Medicine, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany.,Deutsches Zentrum Immuntherapie, DZI, Erlangen, Germany
| | - Timo Rath
- First Department of Medicine, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany.,Deutsches Zentrum Immuntherapie, DZI, Erlangen, Germany
| | - Markus Ferdinand Neurath
- First Department of Medicine, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany.,Deutsches Zentrum Immuntherapie, DZI, Erlangen, Germany
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Vosko S, Shahidi N, Sidhu M, van Hattem WA, Bar-Yishay I, Schoeman S, Tate DJ, Hourigan LF, Singh R, Moss A, Byth K, Lee EYT, Burgess NG, Bourke MJ. Optical Evaluation for Predicting Cancer in Large Nonpedunculated Colorectal Polyps Is Accurate for Flat Lesions. Clin Gastroenterol Hepatol 2021; 19:2425-2434.e4. [PMID: 33992780 DOI: 10.1016/j.cgh.2021.05.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 05/10/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The ability of optical evaluation to diagnose submucosal invasive cancer (SMIC) prior to endoscopic resection of large (≥20 mm) nonpedunculated colorectal polyps (LNPCPs) is critical to inform therapeutic decisions. Prior studies suggest that it is insufficiently accurate to detect SMIC. It is unknown whether lesion morphology influences optical evaluation performance. METHODS LNPCPs ≥20 mm referred for endoscopic resection within a prospective, multicenter, observational cohort were evaluated. Optical evaluation was performed prior to endoscopic resection with the optical prediction of SMIC based on established features (Kudo V pit pattern, depressed morphology, rigidity/fixation, ulceration). Optical evaluation performance outcomes were calculated. Outcomes were reported by dominant morphology: nodular (Paris 0-Is/0-IIa+Is) vs flat (Paris 0-IIa/0-IIb) morphology. RESULTS From July 2013 to July 2019, 1583 LNPCPs (median size 35 [interquartile range, 25-50] mm; 855 flat, 728 nodular) were assessed. SMIC was identified in 146 (9.2%; 95% confidence interval [CI], 7.9%-10.8%). Overall sensitivity and specificity were 67.1% (95% CI, 59.2%-74.2%) and 95.1% (95% CI, 93.9%-96.1%), respectively. The overall SMIC miss rate was 3.0% (95% CI, 2.3%-4.0%). Significant differences in sensitivity (90.9% vs 52.7%), specificity (96.3% vs 93.7%), and SMIC miss rate (0.6% vs 5.9%) between flat and nodular LNPCPs were identified (all P < .027). Multiple logistic regression identified size ≥40 mm (odds ratio [OR], 2.0; 95% CI, 1.0-3.8), rectosigmoid location (OR, 2.0; 95% CI, 1.1-3.7), and nodular morphology (OR, 7.2; 95% CI, 2.8-18.9) as predictors of missed SMIC (all P < .039). CONCLUSIONS Optical evaluation performance is dependent on lesion morphology. In the absence of features suggestive of SMIC, flat lesions can be presumed benign and be managed accordingly.
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Affiliation(s)
- Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Iddo Bar-Yishay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Scott Schoeman
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, School of Medicine University of Queensland, Brisbane, Queensland, Australia; Department of Gastroenterology, Greenslopes Private Hospital, Gallipoli Medical Research Foundation, Brisbane, Queensland, Australia
| | - Rajvinder Singh
- Department of Gastroenterology and Hepatology, Lyell McEwan Hospital, Adelaide, South Australia, Australia
| | - Alan Moss
- Department of Endoscopic Services, Western Health, Melbourne, Victoria, Australia
| | - Karen Byth
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia; WSLHD Research and Education Network, Westmead Hospital, Sydney, New South Wales, Australia
| | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.
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Vosko S, Gupta S, Shahidi N, van Hattem WA, Zahid S, McKay O, Whitfield A, Sidhu M, Tate DJ, Lee EYT, Byth K, Williams SJ, Burgess N, Bourke MJ. Impact of technical innovations in EMR in the treatment of large nonpedunculated polyps involving the ileocecal valve (with video). Gastrointest Endosc 2021; 94:959-968.e2. [PMID: 33989645 DOI: 10.1016/j.gie.2021.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 05/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The endoscopic management of large nonpedunculated colorectal polyps involving the ileocecal valve (ICV-LNPCPs) remains challenging because of its unique anatomic features, with long-term outcomes inferior to LNPCPs not involving the ICV. We sought to evaluate the impact of technical innovations and advances in the EMR of ICV-LNPCPs. METHODS The performance of EMR for ICV-LNPCPs was retrospectively evaluated in a prospective observational cohort of LNPCPs ≥20 mm. Efficacy was measured by clinical success (removal of all polypoid tissue during index EMR and avoidance of surgery) and recurrence at first surveillance colonoscopy. Accounting for the adoption of technical innovations, comparisons were made between an historical cohort (September 2008 to April 2016) and contemporary cohort (May 2016 to October 2020). Safety was evaluated by documenting the frequencies of intraprocedural bleeding, delayed bleeding, deep mural injury, and delayed perforation. RESULTS Between September 2008 to October 2020, 142 ICV-LNPCPs were referred for EMR. Median ICV-LNPCP size was 35 mm (interquartile range, 25-50 mm). When comparing the contemporary (n = 66) and historical cohorts (n = 76) of ICV-LNPCPs, there were significant differences in clinical success (93.9% vs 77.6%, P = .006) and recurrence (4.6% vs 21.0%, P = .019). CONCLUSIONS With technical advances, ICV-LNPCPs can be effectively and safely managed by EMR, independent of lesion complexity. Most patients experience excellent outcomes and avoid surgery.
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Affiliation(s)
- Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Simmi Zahid
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Owen McKay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | | | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Karen Byth
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia; WSLHD Research and Education Network, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Schacher FC, Braga QM, Severo HR, Barlem GG, John JA, Sander GB. EVALUATION OF UNDERWATER ENDOSCOPIC MUCOSAL RESECTION FOR COLORECTAL POLYPS IN AN OUTPATIENT CLINIC IN BRAZIL. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:390-393. [PMID: 34705976 DOI: 10.1590/s0004-2803.202100000-65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 04/30/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Since 2012, a new technique for resection of large polyps has been described, the underwater endoscopic mucosal resection (UEMR). Some advantages that emerge from it is the needless of injection in submucosal layer and a greater chance of complete capture of the polyp. OBJECTIVE There are few studies of UEMR in Brazil. The aim of this study is to evaluate the safety and efficacy of this technique in one Brazilian center. METHODS This case series was conducted from February to December of 2020. Colorectal polyps greater than 9 mm without features of deep submucosal invasion were resected using UEMR. RESULTS Twenty-four large polyps were resected with the UEMR approach from 24 patients. The mean size of the polys was 19 mm, ranging from 12 to 35 mm. All lesions were successful resected and 66% (16/24) were resected en bloc. In histologic analyses, most of them were adenomas (70.8%) and only one had deep submucosal invasion. There were no cases of acute complications, such perforation or acute bleeding. CONCLUSION The UEMR is a safe and feasible procedure. With the emerging data on the procedure, it seems to be a wonderful tool in preventing colorectal cancer and its applicability and scope should be encourage to surpass reference centers.
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Affiliation(s)
| | | | | | | | - Jorge Alberto John
- Hospital Ernesto Dornelles, Serviço de Endoscopia, Porto Alegre, RS, Brasil
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Mathews AA, Draganov PV, Yang D. Endoscopic management of colorectal polyps: From benign to malignant polyps. World J Gastrointest Endosc 2021; 13:356-370. [PMID: 34630886 PMCID: PMC8474698 DOI: 10.4253/wjge.v13.i9.356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/17/2021] [Accepted: 08/09/2021] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) is the third most common cancer worldwide and the second leading cause of cancer related death in the world. The early detection and removal of CRC precursor lesions has been shown to reduce the incidence of CRC and cancer-related mortality. Endoscopic resection has become the first-line treatment for the removal of most precursor benign colorectal lesions and selected malignant polyps. Detailed lesion assessment is the first critical step in the evaluation and management of colorectal polyps. Polyp size, location and both macro- and micro- features provide important information regarding histological grade and endoscopic resectability. Benign polyps and even malignant polyps with superficial submucosal invasion and favorable histological features can be adequately removed endoscopically. When compared to surgery, endoscopic resection is associated with lower morbidity, mortality, and higher patient quality of life. Conversely, malignant polyps with deep submucosal invasion and/or high risk for lymph node metastasis will require surgery. From a practical standpoint, the most appropriate strategy for each patient will need to be individualized, based not only on polyp- and patient-related characteristics, but also on local resources and expertise availability. In this review, we provide a broad overview and present a potential decision tree algorithm for the evaluation and management of colorectal polyps that can be widely adopted into clinical practice.
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Affiliation(s)
- April A Mathews
- Division of Pediatric Gastroenterology, University of Florida, Gainesville, FL 32608, United States
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States
| | - Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States
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Silva MA, Leal C, Ruge A, Fernandes A, Eliseu L, Vasconcelos H. Adenoma Recurrence after Endoscopic Piecemeal Mucosal Resection of Colorectal Flat Lesions: Applicability of the Sydney EMR Recurrence Tool in a Non-Tertiary Centre. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2021; 29:247-255. [PMID: 35979253 PMCID: PMC9274828 DOI: 10.1159/000518445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/23/2021] [Indexed: 11/19/2022]
Abstract
<b><i>Introduction:</i></b> Endoscopic mucosal resection (EMR) is the treatment of choice for non-invasive colorectal flat lesions. When endoscopic piecemeal mucosal resection (EPMR) is performed, endoscopic surveillance is necessary due to the risk of recurrence. The Sydney EMR Recurrence Tool (SERT) is a 0–4 scale that classifies lesions according to size, occurrence of intraprocedural bleeding (IPB) and presence of high-grade dysplasia (HGD). Our goal is to evaluate the applicability of SERT in predicting adenoma recurrence (AR) after EPMR. <b><i>Methods:</i></b> This is a retrospective single-centre study with inclusion of lateral spreading lesions ≥20 mm, consecutively resected by EPMR from March 2010 to February 2018, with at least 1 endoscopic re-evaluation. <b><i>Results:</i></b> A total of 181 lesions were included, corresponding to 174 patients with a mean age of 68 years and male gender predominance (61%; <i>n</i> = 106). The most frequent location was the ascending colon (34%; <i>n</i> = 62). Lesions were assessed according to Paris Classification (PC): 0-IIa: 39% (<i>n</i> = 71); 0-IIb: 24% (<i>n</i> = 43); 0-IIa + Is: 23% (<i>n</i> = 42); 0-IIa + IIb: 6% (<i>n</i> = 11); 0-IIa + IIc: 2% (<i>n</i> = 3). The mean size of the lesions was 33 ± 11 mm, with 25 (14%) being ≥40 mm. IPB occurred in 9 cases (5%), and 44 lesions (24%) displayed HGD. Sixty-six lesions (36.5%) were classified as SMSA (size, morphology, site, and access score) level 4. Adjunctive therapy with argon plasma coagulation (APC) was used in 37% (<i>n</i> = 67) of cases. The 6-month AR rate was 16% (<i>n</i> = 29). According to SERT groups, the AR rate was: SERT 0: 12% (14/120); SERT 1: 17% (6/35); SERT 2: 25% (3/12); SERT 3: 30% (3/10); SERT 4: 75% (3/4). Two of the three SERT variables (size ≥40 mm and IPB) were associated with recurrence at 6 months (<i>p</i> < 0.05). HGD and the remaining tested variables (age, gender, localization, accessibility, PC, use of APC/biopsy forceps and occurrence of delayed bleeding) were not associated with AR. SERT 0 lesions showed an inferior risk of 6-month AR (adjusted OR = 2.62; <i>p</i> = 0.035), with a negative predictive value of 88%. SMSA correlated with SERT (<i>p</i> < 0.001) and SMSA level 4 was associated with 6-month AR (<i>p</i> = 0.007). Lesions classified both as SERT 0 and SMSA level <4 had the lowest 6-month recurrence rate (9.2%). The 24-month recurrence rate was 23% (<i>n</i> = 41). When applying the Kaplan-Meier method, cumulative recurrence was significantly lower in SERT 0 lesions (<i>p</i> = 0.006, log-rank test). <b><i>Discussion/Conclusion:</i></b> Resection of flat colorectal lesions by EPMR has a considerable risk of recurrence, mostly in SERT 1–4 lesions. SERT 0 lesions, especially with SMSA level <4, show a lower risk of recurrent adenoma, which might allow longer intervals to first endoscopic surveillance in the future.
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Postoperative Hospital Outcomes of Elective Surgery for Nonmalignant Colorectal Polyps: Does the Burden Justify the Indication? Am J Gastroenterol 2021; 116:1938-1945. [PMID: 34255758 DOI: 10.14309/ajg.0000000000001374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 06/24/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Despite the increasing availability of advanced endoscopic resections and its favorable safety profile, surgery for nonmalignant colorectal polyps has continually increased. We sought to evaluate readmission rates and outcomes of elective surgery for nonmalignant colorectal polyps on a national level in the United States. METHODS The Nationwide Readmissions Database (2010-2014 [International Classification of Diseases, Ninth Revision] and 2016-2018 [International Classification of Diseases, 10th Revision]) was used to identify all adult subjects (age ≥18 years) who underwent elective surgical resection of nonmalignant colorectal polyps. Multivariable analyses were performed for predictors of postoperative morbidity and 30-day readmission. RESULTS Elective surgery for nonmalignant colorectal polyps was performed in 108,468 subjects from 2010 to 2014 and in 54,956 subjects from 2016 to 2018, most of whom were laparoscopic. Postoperative morbidity and 30-day readmission rates were 20.5% and 8.5% from 2010 to 2014, and 13.0% and 7.6% from 2016 to 2018, respectively. Index admission mortality rates were 0.3-0.4%; mortality rates were higher in those with postoperative morbidity. Multivariable analyses revealed that male sex, ≥3 comorbidities, insurance status, and open surgery predicted an increased risk of both postoperative morbidity and 30-day readmission. In addition, postoperative morbidity (2010-2014 [odds ratio 1.58; 95% confidence interval 1.44-1.74] and 2016-2018 [odds ratio 1.55; 95% confidence interval 1.37-1.75]) predicted early readmission. DISCUSSION In this investigation of national practices, elective surgery for nonmalignant colorectal polyps remains common. There is considerable risk of adverse postoperative outcomes, which highlights the importance of increasing awareness of the range of endoscopic resections and referring subjects to expert endoscopy centers.
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