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Jacques J, Schaefer M, Wallenhorst T, Rösch T, Lépilliez V, Chaussade S, Rivory J, Legros R, Chevaux JB, Leblanc S, Rostain F, Barret M, Albouys J, Belle A, Labrunie A, Preux PM, Lepetit H, Dahan M, Ponchon T, Crépin S, Marais L, Magne J, Pioche M. Endoscopic En Bloc Versus Piecemeal Resection of Large Nonpedunculated Colonic Adenomas : A Randomized Comparative Trial. Ann Intern Med 2024; 177:29-38. [PMID: 38079634 DOI: 10.7326/m23-1812] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Endoscopic resection of adenomas prevents colorectal cancer, but the optimal technique for larger lesions is controversial. Piecemeal endoscopic mucosal resection (EMR) has a low adverse event (AE) rate but a variable recurrence rate necessitating early follow-up. Endoscopic submucosal dissection (ESD) can reduce recurrence but may increase AEs. OBJECTIVE To compare ESD and EMR for large colonic adenomas. DESIGN Participant-masked, parallel-group, superiority, randomized controlled trial. (ClinicalTrials.gov: NCT03962868). SETTING Multicenter study involving 6 French referral centers from November 2019 to February 2021. PARTICIPANTS Patients with large (≥25 mm) benign colonic lesions referred for resection. INTERVENTION The patients were randomly assigned by computer 1:1 (stratification by lesion location and center) to ESD or EMR. MEASUREMENTS The primary end point was 6-month local recurrence (neoplastic tissue on endoscopic assessment and scar biopsy). The secondary end points were technical failure, en bloc R0 resection, and cumulative AEs. RESULTS In total, 360 patients were randomly assigned to ESD (n = 178) or EMR (n = 182). In the primary analysis set (n = 318 lesions in 318 patients), recurrence occurred after 1 of 161 ESDs (0.6%) and 8 of 157 EMRs (5.1%) (relative risk, 0.12 [95% CI, 0.01 to 0.96]). No recurrence occurred in R0-resected cases (90%) after ESD. The AEs occurred more often after ESD than EMR (35.6% vs. 24.5%, respectively; relative risk, 1.4 [CI, 1.0 to 2.0]). LIMITATION Procedures were performed under general anesthesia during hospitalization in accordance with the French health system. CONCLUSION Compared with EMR, ESD reduces the 6-month recurrence rate, obviating the need for systematic early follow-up colonoscopy at the cost of more AEs. PRIMARY FUNDING SOURCE French Ministry of Health.
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Affiliation(s)
- Jérémie Jacques
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | - Marion Schaefer
- Hépato-Gastro-Entérologie, CHRU de Nancy, Nancy, France (M.S., J.-B.C.)
| | | | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital, Hamburg-Eppendorf, Hamburg, Germany (T.R.)
| | - Vincent Lépilliez
- Hépato-Gastro-Entérologie, Hôpital Privé Jean Mermoz, Lyon, France (V.L., S.L.)
| | | | - Jérôme Rivory
- Hépato-Gastro-Entérologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France (J.R., F.R., T.P., M.P.)
| | - Romain Legros
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | | | - Sarah Leblanc
- Hépato-Gastro-Entérologie, Hôpital Privé Jean Mermoz, Lyon, France (V.L., S.L.)
| | - Florian Rostain
- Hépato-Gastro-Entérologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France (J.R., F.R., T.P., M.P.)
| | - Maximilien Barret
- Hépato-Gastro-Entérologie, Hôpital Cochin, Paris, France (S.C., M.B., A.B.)
| | - Jérémie Albouys
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | - Arthur Belle
- Hépato-Gastro-Entérologie, Hôpital Cochin, Paris, France (S.C., M.B., A.B.)
| | - Anaïs Labrunie
- Centre d'Epidémiologie de Biostatistiques et Méthodologie de la Recherche (CEBIMER), CHU de Limoges, Limoges, France (A.L., P.-M.P., J.M.)
| | - Pierre-Marie Preux
- Centre d'Epidémiologie de Biostatistiques et Méthodologie de la Recherche (CEBIMER), CHU de Limoges, Limoges, France (A.L., P.-M.P., J.M.)
| | - Hugo Lepetit
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | - Martin Dahan
- Hépato-Gastro-Entérologie, CHU de Limoges, Limoges, France (J.J., R.L., J.A., H.L., M.D.)
| | - Thierry Ponchon
- Hépato-Gastro-Entérologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France (J.R., F.R., T.P., M.P.)
| | - Sabrina Crépin
- Service de Pharmacologie-Toxicologie et Pharmacovigilfance-Unité de Vigilance des Essais Cliniques, CHU de Limoges, Limoges, France (S.C.)
| | - Loïc Marais
- Direction de la Recherche et de l'Innovation, CHU de Limoges, Limoges, France (L.M.)
| | - Julien Magne
- Centre d'Epidémiologie de Biostatistiques et Méthodologie de la Recherche (CEBIMER), CHU de Limoges, Limoges, France (A.L., P.-M.P., J.M.)
| | - Mathieu Pioche
- Hépato-Gastro-Entérologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France (J.R., F.R., T.P., M.P.)
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Wei A, Ma S, Dou Y, Wang X, Wu J, Zhou S, Deng Y, Liu X, Li D, Yang M. The safety and efficacy of remimazolam tosylate combined with propofol in upper gastrointestinal endoscopy: A multicenter, randomized clinical trial. PLoS One 2023; 18:e0282930. [PMID: 37535618 PMCID: PMC10399878 DOI: 10.1371/journal.pone.0282930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/09/2023] [Indexed: 08/05/2023] Open
Abstract
INTRODUCTION Hypotension is the most common adverse event under propofol-mediated sedation and is possible to cause varying degrees of damage to patients. Whereas remimazolam has a poorer sedative effect than propofol. AIM The aim of this study was to explore the advantages of the combination of remimazolam tosylate and propofol. METHODS 304 patients were divided into the remimazolam tosylate group (RT group), the propofol group (P group), and the remimazolam tosylate plus propofol group(R+T group). The primary outcome was the incidence of hypotension. Secondary outcomes included the results of sedation and recovery. The safety results mainly include the incidence of Hypotension, adverse respiratory events, postoperative nausea and vomiting, hiccup, cough, body movement and bradycardia. RESULTS The incidence of hypotension was 56.7% in the P group, 12.6% in the RT group, and 31.3% in the R+P group, three groups of pairwise comparisons showed statistical differences, with P< 0.001. The incidence of body movement was significantly higher in the RT group (26.1%) than in the P group (10.3%) and the R+P group (12.5%), P = 0.004. The endoscopist satisfaction was higher in the P (3.87±0.44) and R+P (3.95±0.22)groups than in the RT(3.53±0.84) group. The incidence of adverse events, in descending order, was P group, RT group, and R+P group (93.8%vs.61.3%vs.42.7%). CONCLUSION Co-administration had fewer adverse events than propofol monotherapy, also had a better sedative effect and higher endoscopist satisfaction than remimazolam monotherapy. TRIAL REGISTRATION Clinical trial registration number: NCT05429086.
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Affiliation(s)
- Ai Wei
- Department of Anesthesiology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Shijin Ma
- Department of Anesthesiology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yuzhe Dou
- Department of Anesthesiology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaojun Wang
- Department of Anesthesiology, Yibin First People's Hospital, Yibin, China
| | - Jianxiong Wu
- Department of Anesthesiology, Chinese Traditional Medicine Hospital of Leshan, Leshan, China
| | - Shuzhi Zhou
- Department of Anesthesiology, Ya'an People's Hospital, Ya'an, China
| | - Yanfang Deng
- Department of Anesthesiology, the first People's Hospital of Liangshan Yi Autonomous Prefecture, Liangshan, China
| | - Xinquan Liu
- Department of Anesthesiology, Ziyang People's Hospital, Ziyang, China
| | - Dongming Li
- Department of Anesthesiology, Bazhong Central Hospital, Bazhong, China
| | - Mengchang Yang
- Department of Anesthesiology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Determinants of symptom burden related to bowel preparation for colonoscopy. Dig Liver Dis 2022; 54:1554-1560. [PMID: 35778229 DOI: 10.1016/j.dld.2022.06.005] [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: 03/15/2022] [Revised: 05/11/2022] [Accepted: 06/07/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Symptoms developing during bowel preparation are major concerns among subjects who refuse the procedure. AIMS We aimed to explore the determinants of symptoms occurring during preparation among patients undergoing elective colonoscopy. METHODS This is a prospective multicenter study conducted in 10 Italian hospitals. A multidimensional approach collecting socio-demographic, clinical, psychological and occupational information before colonoscopy through validated instruments was used. Outcome was a four-category cumulative score based on symptoms occurring during preparation, according to the Mayo Clinic Bowel Prep Tolerability Questionnaire, weighted by intensity. Missing values were addressed through multiple imputation. Odds ratios (OR) and 95% confidence intervals (CI) were estimated through multivariate logistic regression models. RESULTS 1137 subjects were enrolled. Severe symptoms were associated with female sex (OR=3.64, 95%CI 1.94-6.83), heavier working hours (OR=1.13, 95% CI=1.01-1.25), previous gastrointestinal symptoms (OR=7.81, 95% CI 2.36-25.8 for high score), somatic symptoms (OR=2.19, 95% CI=1.06-4.49 for multiple symptoms), day-before regimen (OR=2.71, 95%CI 1.28-5.73). On the other hand, age ≥60 years (OR=0.10, 95% CI 0.02-0.44) and good mood (p=0.042) were protective factors. A high-risk profile was identified, including women with low mood and somatic symptoms (OR=15.5, 95%CI 4.56-52.7). CONCLUSIONS We identified previously unreported determinants of symptoms burdening bowel preparation and identified a particularly vulnerable phenotype. Symptoms during preparation especially impact heavier working activity.
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Stéphane S, Timothée W, Jérémie A, Raphael O, Martin D, Emmanuelle P, Elodie L, Quentin D, Nikki C, Sonia B, Hugo L, Guillaume G, Romain L, Mathieu P, Sophie G, Jeremie J. Endoscopic submucosal dissection or piecemeal endoscopic mucosal resection for large superficial colorectal lesions: A cost effectiveness study. Clin Res Hepatol Gastroenterol 2022; 46:101969. [PMID: 35659602 DOI: 10.1016/j.clinre.2022.101969] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/20/2022] [Accepted: 05/30/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Endoscopic management is preferred to surgical management for large superficial colorectal lesions. However, the optimal endoscopic resection strategy (piecemeal endoscopic mucosal resection [pEMR] or endoscopic submucosal dissection [ESD]) is still debated from an economical point of view. To date, in France, there is no Health Insurance reimbursement rate for the hospital stays related to ESD. We searched to estimate the global cost of colorectal ESD and to define the most cost-effectiveness endoscopic strategy. METHODS A model was created to compare the cost-effectiveness of ESD and pEMR according to optical diagnosis (Japan NBI Expert Team [JNET], laterally spreading tumour [LST], CONECCT). We distinguished three groups from the same multicentre ESD cohort and compared the medical and economic outcomes: real-life ESD data (Universal-ESD or U-ESD) compared to modelled selective ESD (S-ESD JNET; S-ESD LST; S-ESD CONECCT) and exclusive pEMR strategies (Universal-EMR or U-EMR). RESULTS The en-bloc, R0, and curative resection rates were 97.5%, 86.5%, and 82.6%, respectively in the real life French ESD cohort of 833 colorectal lesions. U-ESD was the least-expensive strategy, with a global cost of 2,858,048.17 €, i.e. 3,431.03 €/patient and was also the most effective strategy because it avoided 774 surgeries, which was more than any other strategy. It outperformed S-ESD CONNECT (global cost = 2,951,411.44 €, and 3,543.11 €/patient, 765 surgeries avoided, S-ESD LST (global cost = 3,055,951.53 €, and 3,668.61 €/patient, 749 surgeries avoided), and S-ESD JNET (global cost = 3,547,426.97 € and 4,258.62 €/patient, 704 surgeries avoided) and U-EMR (global cost = 4,060,547.62 € and 4,874.61 €/patient, 620 surgeries avoided). Even though a model which optimized pEMR results (0% technical failure, 0% primary surgery), U-EMR strategy remained the most expansive strategy and the one that avoided the least surgeries. CONCLUSION ESD for all LSTs upper than 20 mm is more cost-effective than pEMR, and S-ESD.
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Affiliation(s)
- Scheer Stéphane
- Gastroenterology Department, University Hospital of Poitiers, 86000 Poitiers, France
| | - Wallenhorst Timothée
- Gastroenterology Department, University Hospital of Rennes, 35000 Rennes, France
| | - Albouys Jérémie
- Gastroenterology Department, University Hospital of Limoges, 87042 Limoges, France
| | - Olivier Raphael
- Gastroenterology Department, University Hospital of Poitiers, 86000 Poitiers, France
| | - Dahan Martin
- Gastroenterology Department, University Hospital of Limoges, 87042 Limoges, France
| | | | - Leclerc Elodie
- Gastroenterology Department, University Hospital of Rennes, 35000 Rennes, France
| | - Denost Quentin
- Colorectal and Pelvic Surgery, Bordeaux University Hospital, 33604 Bordeaux, France
| | - Christou Nikki
- Digestive Surgery, Limoges University Hospital, 87042 Limoges, France
| | | | - Lepetit Hugo
- Gastroenterology Department, University Hospital of Limoges, 87042 Limoges, France
| | - Gschwind Guillaume
- Public Health Care Department, University Hospital of Limoges, 87042 Limoges, France
| | - Legros Romain
- Gastroenterology Department, University Hospital of Limoges, 87042 Limoges, France
| | - Pioche Mathieu
- Gastroenterology Department, Hospital Edouard Heriot, Hospices civils de Lyon, 69003 Lyon, France
| | - Geyl Sophie
- Gastroenterology Department, University Hospital of Limoges, 87042 Limoges, France
| | - Jacques Jeremie
- Gastroenterology Department, University Hospital of Limoges, 87042 Limoges, France.
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