Reducing the incidence and mortality of colon cancer: mass screening and colonoscopic polypectomy

Screening of normal endoscopic large bowel biopsies with interpretable graph learning: a retrospective study

OBJECTIVE

To develop an interpretable artificial intelligence algorithm to rule out normal large bowel endoscopic biopsies, saving pathologist resources and helping with early diagnosis.

DESIGN

A graph neural network was developed incorporating pathologist domain knowledge to classify 6591 whole-slides images (WSIs) of endoscopic large bowel biopsies from 3291 patients (approximately 54% female, 46% male) as normal or abnormal (non-neoplastic and neoplastic) using clinically driven interpretable features. One UK National Health Service (NHS) site was used for model training and internal validation. External validation was conducted on data from two other NHS sites and one Portuguese site.

RESULTS

Model training and internal validation were performed on 5054 WSIs of 2080 patients resulting in an area under the curve-receiver operating characteristic (AUC-ROC) of 0.98 (SD=0.004) and AUC-precision-recall (PR) of 0.98 (SD=0.003). The performance of the model, named Interpretable Gland-Graphs using a Neural Aggregator (IGUANA), was consistent in testing over 1537 WSIs of 1211 patients from three independent external datasets with mean AUC-ROC=0.97 (SD=0.007) and AUC-PR=0.97 (SD=0.005). At a high sensitivity threshold of 99%, the proposed model can reduce the number of normal slides to be reviewed by a pathologist by approximately 55%. IGUANA also provides an explainable output highlighting potential abnormalities in a WSI in the form of a heatmap as well as numerical values associating the model prediction with various histological features.

CONCLUSION

The model achieved consistently high accuracy showing its potential in optimising increasingly scarce pathologist resources. Explainable predictions can guide pathologists in their diagnostic decision-making and help boost their confidence in the algorithm, paving the way for its future clinical adoption.

Evaluation of anesthesia quality with three methods: "propofol + fentanyl" vs. "propofol + fentanyl + lidocaine" vs. "propofol + fentanyl + lidocaine + ketamine" in patients referred to the scoping ward

Introduction:

Toleration of the complexity and pain of interventions such as endoscopy and colonoscopy is highly difficult for patients. Considering the disagreement on the method of injection of propofol, this study was performed to evaluate the quality of anesthesia using the three methods of propofol + fentanyl, propofol + fentanyl + lidocaine, and propofol + fentanyl + lidocaine + ketamine.

Methods:

This one-way blind clinical trial study included 99 patients who were admitted in three groups by block randomization method. In a group of patients that were sedated with propofol + fentanyl + lidocaine + ketamine, the dose of all drugs is reduced by half the amount of the other groups. Variables included age, sex, frequency of cough, apnea, need for jaw thrust maneuver, O₂ saturation, duration of recovery, and procedural satisfaction. Data were analyzed using SPSS version 20.0. P value of < 0.05 was considered to be significant.

Results:

The three groups were similar in terms of demographic characteristics. The effects of the three sedation protocols on the variables showed that patient’s apnea, cough, O₂ saturation, and also proceduralist satisfaction in the group of the patient that sedated with four drugs was significantly higher (P < 0.05) than other groups. But there was no significant difference between the three groups when comparing the recovery time and need for jaw thrust during the procedure.

Conclusion:

The findings of the present study showed that the use of combination of “propofol + fentanyl + lidocaine + ketamine” with lower doses, significantly results in higher quality sedation compared with higher doses of “propofol + fentanyl + lidocaine” or “propofol + fentanyl” for scoping procedures.

Anorectal emergencies: WSES-AAST guidelines

Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Incidental Polyp on Colectomy Specimen is Linked with Higher Odds of Polyp on Interval Colonoscopy

BACKGROUND

Incidentally found polyps on surgical pathology after colectomy is an underreported phenomenon, and management guidelines are lacking. Elucidation of the significance of incidental polyps is needed to determine if post-operative endoscopic surveillance modification is warranted. We sought to determine the relationship between incidental polyp on colectomy specimen and findings on post-operative colonoscopy.

MATERIALS AND METHODS

A multi-institutional retrospective review was performed on patients that underwent colorectal resection from 2018-2019. Surgical pathology was reviewed for polyps and assigned as expected or incidental based on pre-operative colonoscopy. If performed, post-operative colonoscopy was reviewed for new lesion identification. The odds of detecting new lesion on post-operative colonoscopy was compared between cases with incidental polyp on surgical specimen and patients without incidental findings.

RESULTS

In 243 colorectal resections, incidental polyps were identified in 55 cases(22.6%). Post-operative colonoscopy was completed in 65 cases(26.7%) with new polyp detected in 24 cases(9.88%). Of those, 10 had an incidental polyp previously identified on surgical specimen while 14 did not. The presence of incidental surgical specimen polyp was associated with a greater than two-fold higher odds of detecting new polyp on post-operative colonoscopy(odds-ratio 2.76, 95% confidence interval 1.15-6.63;P = 0.023).

CONCLUSION

This analysis revealed a high frequency of incidental polyps on surgical specimens with an increased rate of newly found lesions on post-operative colonoscopy. Incidental polyps may be a risk factor for other missed lesions still within the patient. Therefore, providers should consider surveillance interval modification on an individual basis in the setting of incidental surgical specimen polyps.

Increased risk of preneoplastic colonic lesions and colorectal carcinoma in acromegaly: multicenter case-control study

PURPOSE

Current international guidelines recommend colonoscopy in patients with acromegaly at the time of diagnosis, even though the risk of developing colorectal neoplasm is still controversial. The main objective of this Argentine multicenter study was to analyze through screening colonoscopy the presence of advanced neoplastic lesions considered as precancerous, in patients with acromegaly compared to a control group.

METHODS

This is a case-control retrospective study. Full length colonoscopy of 70 acromegalic patients and 128 control subjects were studied. Polyps were classified into non pre-cancerous lesions and advance neoplastic lesions which included advanced adenomas (preneoplastic) and colorectal carcinomas.

RESULTS

Thirty three out of 70 acromegalic patients and 32 out of 128 subjects controls presented polyps in the colonoscopy [47.1% vs 25%, p = 0.002, OR 2.68]. Non precancerous polyps were found in 11 (15.7%) and 23 (17.9%) (p = 0.690), while advanced neoplastic lesions were found in 22 (31.4%) and 9 (7.0%) (p = 0,0001 - OR: 6.06) patients and controls respectively. Advanced adenomas and colorectal carcinomas were found in 18 (27.3%) and 9 (7.0%) (p = 0,0006-OR: 4,57), and 4 (5.7%) and 0 (0.0%) p = 0.0063) of patients and controls respectively. The presence of insulin resistance was the only statistically significant associated factor among acromegalic patients with and without colonic polyps.

CONCLUSIONS

Our findings show an increased risk of preneoplastic colonic lesions and colorectal carcinoma in patients with chronic and sustained GH excess compared to a control group. This supports the recommendation to perform screening colonoscopy at diagnosis of acromegaly.

Protein-based nanoplatform for detection of tumorigenic polyps in the colon via noninvasive mucosal routes

The use of nanoparticulate systems to diagnose and treat tumors has gained momentum with the rapid development of nanomedicine. Many nanotheranostics fail due to insufficient bioavailability and low accumulation at the tumor site, resulting in undesirable side effects. We describe the use of an engineered hepatitis E viral nanoparticle (HEVNP) with enhanced bioavailability, tissue retention and mucosal penetration capacities. HEVNP is a modular nanocapsule that can encapsulate heterologous nucleotides, proteins and inorganic metals, such as ferrite oxide nanoparticles. Additionally, the exterior protruding arms of HEVNP is composed of loops that are used for chemical coupling of targeting and therapeutic peptides. We propose the use of HEVNP to target colorectal cancer (i.e., polyps) with imaging-guided delivery using colonoscopy.

Predictors of Neoplasia in Colonic Wall Thickening Detected via Computerized Tomography

Introduction

Colonic wall thickening (CWT) is frequently observed incidentally via abdominal computerized tomography (aCT). Although the general approach to evaluating incidental CWT is a colonoscopic examination, there is a lack of definitive recommendation guidelines. Thus, we aimed to determine neoplasia rates and identify the factors predictive of neoplasia via colonoscopic examinations of patients with CWT incidentally diagnosed via aCT.

Methods

We retrospectively reviewed 5,300 colonoscopy reports. A total of 122 patients who had CWT incidentally observed via aCT were included in the study. CWT was graded as mild (3-5 mm), moderate (6-12 mm), or severe (≥12 mm). A logistic regression model was used to determine the predictive factors for neoplasia.

Results

The mean age of the patients was 60 years, and abnormal findings were noted in 52% of the colonoscopies. Neoplastic lesions were detected in 24 patients (19.6%), while colon adenocarcinoma was detected in 8 patients (6.5%). Multivariate analysis showed that moderate-severe, focal, and asymmetric CWT were independent factors for predicting neoplasia (p=0.049, p=0.033, and p=0.018, respectively).

Conclusion

Pathological findings can be noted via colonoscopic examination in cases of incidental CWT; therefore, patients with moderate-severe, focal, or asymmetric CWT require colonoscopic examination for the purpose of detecting neoplasia.

EXPERIMENTAL ASSESSMENT OF INTACT COLON DEFORMATION UNDER LOCAL FORCES APPLIED BY MAGNETIC CAPSULE ENDOSCOPES

Magnetically guided capsule endoscopy is a promising technology for clinical application. A platform that simulates the magnetic capsule endoscope system is built to study the deformation process of the colon when its lumen suffers local forces. Force-displacement curves of the porcine large intestine under various experiment conditions, including different loading positions (haustra or taeniae coli), loading directions, colon inner pressures and specimen lengths, were measured to analyze the mechanical behavior of the intact large intestine during interactions with magnetic capsule endoscopes. In the practical application of the magnetic capsule endoscope, these data are imperative to optimize the control scheme and reduce operation risks. Based on our experiments, the taeniae coli of the intact large intestine show higher linear stiffness than the haustra, and inflation reduces the linear stiffness of the colon. Magnetic capsule with small edge radii can more easily damage or even perforate the colon. Based on our test results, we suggest that the force applied to the colon should be limited to below 17[Formula: see text]N when the capsule is actuated forward along the colon and limited to below 10[Formula: see text]N when the capsule is vertical to the colon during lesion screening.

A Circulating miRNA-Based Scoring System Established by WGCNA to Predict Colon Cancer

Introduction

Circulation microRNAs (miRNAs) perform as potential diagnostic biomarkers of many kinds of cancers. This study is aimed at identifying circulation miRNAs as diagnostic biomarkers in colon cancer.

Methods

We conducted a weighted gene coexpression network analysis (WGCNA) in miRNAs to find out the expression pattern among circulation miRNAs by using a “WGCNA” package in R. Correlation analysis was performed to find cancer-related modules. Differentially expressed miRNAs (DEmiRs) in colon cancer were identified by a “limma” package in R. Hub gene analysis was conducted for these DEmiRs in the cancer-related modules by the “closeness” method in cytoscape software. Then, logistic regression was performed to identify the independent risk factors, and a scoring system was constructed based on these independent risk factors. Then, we use data from the GEO database to confirm the reliability of this scoring system.

Results

A total of 9 independent coexpression modules were constructed based on the expression levels of 848 miRNAs by WGCNA. After correlation analysis, green (cor = 0.77, p = 3 × 10^‐25) and yellow (cor = 0.65, p = 6 × 10^‐16) modules were strongly correlated with cancer development. 20 hub genes were found after hub gene analysis in these DEmiRs by cytoscape. Among all these hub genes, hsa-miR-23a-3p (OR = 2.6391, p = 6.23 × 10^‐5) and hsa-miR-663a (OR = 1.4220, p = 0.0069) were identified as an independent risk factor of colon cancer by multivariate regression. Furthermore, a scoring system was built to predict the probability of colon cancer based on both of these miRNAs, the area under the curve (AUC) of which was 0.828. Data from GSE106817 and GSE112264 was used to confirm this scoring system. And the AUC of them was 0.980 and 0.917, respectively.

Conclusion

We built a scoring system based on circulation hub miRNAs found by WGCNA to predict the development of colon cancer.

Survival and quality of life after surgery for colorectal cancer in the elderly: a comparative study

BACKGROUND

the aim of this study was to analyze the clinical results of the multidisciplinary management of elderly patients with colorectal cancer in a single center and to describe postoperative quality of life.

METHODS

a comparative study was designed to compare the results and quality of life of patients treated in our center for colon cancer, aged from 80 to 84 years (study group) compared to a control group (aged form 75 to 79 years of age). Morbidity, mortality, oncological results and quality of life were analyzed.

RESULTS

eighty-seven patients aged between 80 and 84 years of age (study group) were compared to a control group, which was formed by 91 patients aged from 75 to 79 years of age. There were no significant differences in technique and morbidity. Survival at 30 days, 90 days and at the end of follow-up (median 48 months) were similar in both groups. There were no differences in quality of life except for one item with regard to physical function (p = 0.0138).

CONCLUSION

similar clinical results and quality of life were achieved after treating elderly patients with colon cancer with a multidisciplinary management approach.

Management of Common Benign Anorectal Disease: What All Physicians Need to Know

Benign anorectal conditions produce anal pain, rectal bleeding, or discharge from the perianal region, which are highly prevalent symptoms in the general population. Hemorrhoidal disease, anal fissure, perianal abscess, proctalgia syndromes, and pruritus anii are the most common clinical disorders. Well-trained physicians, irrespective of their specialty, can treat most of these disorders and refer them to a specialist in proctology only when necessary. The aim of this review is to provide a practical guide to the management of benign anorectal disorders in terms of their initial management and the criteria for specialist referral.

Detection of human papillomavirus infection by molecular tests and its relation to colonic polyps and colorectal cancer

Objectives:

To prospectively examine the association between human papilloma virus (HPV) colonization of the colonic mucosa and the development of colorectal polyps (CRPs), and colorectal cancer (CRC) in Saudi Arabia.

Methods:

A case control study was performed between January 2013 and December 2014. All eligible patients underwent standard diagnostic colonoscopy. Patients with polyps or colorectal cancer were considered cases, while those with any other endoscopic findings were controls. Biopsy samples from polyps and tumors, and/or from normal colonic mucosa were acquired. Human papilloma virus colonization was detected using a hybrid capture technique of samples taken from both normal tissue, and CRPs and CRC. The association between HPV and CRPs/CRC was evaluated.

Results:

A total of 132 patients were recruited. The mean age was 53 (±15.9) years. Sixty patients had endoscopically detectable CRPs/CRC, and 72 had either inflammation or normal endoscopic evaluations. Only 4 (0.8%) of the 132 samples that were collected and analyzed were positive for the HPV gene. Statistical analysis did not identify any significant association between HPV colonization and the presence of CRPs/CRC. The only significant predictor of detecting CRPs/CRC on colonoscopy was symptomatic presentation (odds ratio=11.072, 95% confidence interval 4.7-26.2, p<0.001).

Conclusion:

Human papilloma virus colonic colonization is rare in Saudi Arabia. An association between HPV colonization and CRP/CRC development could not be identified in this cohort of patients.

Executive Summary - The Association of Colon & Rectal Surgeons of India (ACRSI) Practice Guidelines for the Management of Haemorrhoids-2016

This paper outlines the recommendations from the Association of Colon & Rectal Surgeons of India (ACRSI) practice guidelines for the management of haemorrhoids-2016. It includes diagnosis and management of haemorrhoids including dietary, non-surgical, and surgical techniques. These guidelines are intended for the use of general practitioners, general surgeons, colorectal surgeons, and gastrointestinal surgeons in India.

High risk factors for recurrence after resection of colorectal polyps

AIM: To investigate the high risk factors for recurrence after resection of colorectal polyps.

METHODS: A retrospective analysis was performed of patients who underwent endoscopic resection of colorectal polyps more than twice from January 2012 to December 2015 at Shanghai Putuo District Central Hospital to identify the high risk factors for recurrence.

RESULTS: A total of 54 patients was included. Univariate analysis showed that male gender, old age, low intestinal cleaning degree, adenomatous polyps, polyps < 1 cm, APC electric cauterization combined with high frequency electrocoagulation, and multiple polyps were risk factors for postoperative recurrence of colorectal polyps. Multivariate analysis showed that only age was an independent risk factor for postoperative recurrence of colorectal polyps.

CONCLUSION: Age, gender, polyp number, polyp pathology, and intestinal cleanliness are risk factors for postoperative recurrence of colorectal polyps. Insufficient bowel preparation and smaller polyps will increase the rate of missed diagnosis and increase the risk of postoperative recurrence.

Colonoscopy sedation: clinical trial comparing propofol and fentanyl with or without midazolam

Colonoscopy is one of the most common procedures. Sedation and analgesia decrease anxiety and discomfort and minimize risks. Therefore, patients prefer to be sedated when undergoing examination, although the best combination of drugs has not been determined. The combination of opioids and benzodiazepines is used to relieve the patient's pain and discomfort. More recently, propofol has assumed a prominent position. This randomized prospective study is unique in medical literature that specifically compared the use of propofol and fentanyl with or without midazolam for colonoscopy sedation performed by anesthesiologists. The aim of this study was to evaluate the side effects of sedation, discharge conditions, quality of sedation, and propofol consumption during colonoscopy, with or without midazolam as preanesthetic. The study involved 140 patients who underwent colonoscopy at the University Hospital of the Federal University of Juiz de Fora. Patients were divided into two groups: Group I received intravenous midazolam as preanesthetic 5min before sedation, followed by fentanyl and propofol; Group II received intravenous anesthesia with fentanyl and propofol. Patients in Group II had a higher incidence of reaction (motor or verbal) to the colonoscope introduction, bradycardia, hypotension, and increased propofol consumption. Patient satisfaction was higher in Group I. According to the methodology used, the combination of midazolam, fentanyl, and propofol for colonoscopy sedation reduces propofol consumption and provides greater patient satisfaction.

Detection rate of colorectal adenoma or cancer in unselected colonoscopy patients: Indonesian experience in a private hospital

BACKGROUND

Colorectal cancer is currently the third most common cancer in Indonesia, yet colonoscopy--the most accepted mode of screening to date--is not done routinely and national data are still lacking.

OBJECTIVE

To determine the detection rate of colorectal cancers and adenomas in unselected patients undergoing colonoscopy for various large bowel symptoms at the Digestive Disease and GI Oncology Centre, Medistra Hospital in Jakarta, Indonesia.

MATERIALS AND METHODS

Colonoscopy data from January 2009 to December 2012 were reviewed. New patients referred for colonoscopy were included. Data collected were patient demographic and significant colonoscopy findings such as the presence of hemorrhoids, colonic polyps, colonic diverticula, inflammation, and tumor mass. Histopathological data were obtained for specimens taken by biopsy. Associations between categorical variables were analyzed using chi-square test, while mean differences were tested using the t-test.

RESULTS

A total of, 1659 cases were included in this study, 889 (53.6%) of them being men. Polyps or masses were found in 495 (29.8%) patients while malignancy was confirmed in 74 (4.5%). Patients with a polyp or mass were significantly older (60.2 vs 50.8 years; p<0.001; t-test) and their presence was significantly associated with male gender (35.0% vs 23.9%; prevalent ratio [PR] 1.71; 95% confidence interval [CI] 1.38-2.12; p<0.001) and age>50 years (39.6% vs 16.6%; PR 3.29; 95% CI 2.59-4.12; p<0.001). Neoplastic lesions was found in 257 (16.1%), comprising 180 (11.3%) adenomas, 10 (0.6%) in situ carcinomas, and 67 (4.2%) carcinomas.

CONCLUSIONS

Polyps or masses were found in 30% of colonoscopy patients and malignancies in 16.1%. These figures do not represent the nation-wide demographic status of colorectal cancer, but may reflect a potentially increasing major health problem with colorectal cancer in Indonesia.

[Colonoscopy sedation: clinical trial comparing propofol and fentanyl with or without midazolam]

Colonoscopy is one of the most common procedures. Sedation and analgesia decrease anxiety and discomfort and minimize risks. Therefore, patients prefer to be sedated when undergoing examination, although the best combination of drugs has not been determined. The combination of opioids and benzodiazepines is used to relieve the patient's pain and discomfort. More recently, propofol has assumed a prominent position. This randomized prospective study is unique in medical literature that specifically compared the use of propofol and fentanyl with or without midazolam for colonoscopy sedation performed by anesthesiologists. The aim of this study was to evaluate the side effects of sedation, discharge conditions, quality of sedation, and propofol consumption during colonoscopy, with or without midazolam as preanesthetic. The study involved 140 patients who underwent colonoscopy at the University Hospital of the Federal University of Juiz de Fora. Patients were divided into two groups: Group I received intravenous midazolam as preanesthetic five minutes before sedation, followed by fentanyl and propofol; Group II received intravenous anesthesia with fentanyl and propofol. Patients in Group II had a higher incidence of reaction (motor or verbal) to the colonoscope introduction, bradycardia, hypotension, and increased propofol consumption. Patient satisfaction was higher in Group I. According to the methodology used, the combination of midazolam, fentanyl, and propofol for colonoscopy sedation reduces propofol consumption and provides greater patient satisfaction.

The prevalence and factors for cancer screening behavior among people with severe mental illness in Hong Kong

OBJECTIVES

Screening is useful in reducing cancer incidence and mortality. People with severe mental illness (PSMI) are vulnerable to cancer as they are exposed to higher levels of cancer risks. Little is known about PSMI's cancer screening behavior and associated factors. The present study examined the utilization of breast, cervical, prostate, and colorectal cancer screening among PSMI in Hong Kong and to identify factors associated with their screening behaviors.

METHOD

591 PSMI from community mental health services completed a cross-sectional survey.

RESULTS

The percentage of cancer screening behavior among those who met the criteria for particular screening recommendation was as follows: 20.8% for mammography; 36.5% for clinical breast examination (CBE); 40.5% for pap-smear test; 12.8% for prostate examination; and 21.6% for colorectal cancer screening. Results from logistic regression analyses showed that marital status was a significant factor for mammography, CBE, and pap-smear test; belief that cancer can be healed if found early was a significant factor for pap-smear test and colorectal screening; belief that one can have cancer without having symptoms was a significant factor for CBE and pap-smear test; belief that one will have a higher risk if a family member has had cancer was a significant factor for CBE; and self-efficacy was a significant factor for CBE and pap-smear test behavior.

CONCLUSIONS

Cancer screening utilization among PSMI in Hong Kong is low. Beliefs about cancer and self-efficacy are associated with cancer screening behavior. Health care professionals should improve the knowledge and remove the misconceptions about cancer among PSMI; self-efficacy should also be promoted.

Hemorrhoids and fistulas: new solutions to old problems

Symptoms thought related to hemorrhoids must be carefully considered before intervention. The first line of therapy for any hemorrhoidal complaint remains conservative management with increased fluid and fiber intake and appropriate modification of toileting behavior. Bleeding in grades 1 and 2 hemorrhoids that does not respond to this can be satisfactorily and safely managed with office-based therapies; some grade 3 hemorrhoids would also respond to this, though more treatment sessions would likely be required. Operative therapy is the best choice for management of persistently symptomatic grade 2 disease and for grades 3 and 4 symptomatic hemorrhoids as well. With proper patient selection and preparation, along with a familiarity with instrumentation and techniques, good results can be obtained with newer operative interventions for internal hemorrhoids. Outcomes must always be compared with those obtained with classic excisional hemorrhoidectomy.

Gallstones are associated with colonic adenoma: a meta-analysis

BACKGROUND

Increased levels of secondary bile acids after gallstone disease and cholecystectomy are believed to increase the risk of colorectal cancer. It remains unclear whether there is a similar risk of developing adenomas. The aim of this meta-analysis was to determine the risk of developing colonic adenomas following gallstone disease or cholecystectomy.

METHODS

The study was based on a systematic search of PubMed, MEDLINE, EMBASE, and Current Contents (1950-2012). Selection criteria were developed to sort for studies exploring the relationship between cholelithiasis, cholecystectomy, and colonic adenoma in an adult population. A random-effects model was used to generate pooled odds ratios (OR) and 95 % confidence intervals (CI). Publication bias and heterogeneity were assessed.

RESULTS

Of the 1,276 studies identified, 14 were suitable for final analysis. There were 253,059 subjects in total, 42,543 of whom were diagnosed with colonic adenoma, and 28,281 of whom had gallstones or underwent cholecystectomy. There was a significant risk of developing colonic adenoma if gallstones were present (OR = 2.26; 95 % CI = 1.83-2.81). A risk was also seen with cholecystectomy (OR = 1.15; 95 % CI = 1.04-1.26), but this risk was negated when only adjusted odds were selected (OR = 1.01; 95 % CI = 0.91-1.12). No publication bias and only low levels of heterogeneity existed.

CONCLUSIONS

Gallstones increase the risk of colonic adenoma. No association exists with cholecystectomy.

[Endoscopic mucosal resection of colorectal tumors--our first experience]

BACKGROUND/AIM

Endoscopic mucosal resection (EMR) or mucosectomy is an interventional procedure for minimal invasive endoscopic removal of benign and malignant digestive tract tumors. Mucosectomy removes flat and sessile neoplasms, early colorectal cancer (CRC) confined to mucosa or submucosa and lateral spreading tumors. The aim of the study was to show our first experience in application of this procedure in everyday practice in regarding completeness and efficacy of the procedure, complication rate and incidence of recurrent adenomas.

METHODS

In the prospective study 51 colorectal adenomas were removed in 44 patients by EMR.

RESULTS

Single mucosectomy was done in 43 patients, while multiple (8) in one patient. Complete resection was obtained in all procedures. In 36 (68.62%) procedures "en block" resection was done, but in 15 (31.37%) procedures "piece meal" resection was performed. Synchronous colorectal tumors (benign or malignant) were detected in 20 (45.45%) patients. Moderate dysplasia was found in 30 (58.82%) adenomas, but high grade dysplasia in 9 (17.64%) of adenomas. Intramucosal CRC was detected in 11.77% of adenomas. A total of 37 (72.54%) advanced adenomas were removed. There were 3 (5.88%) of recurrent adenomas, 6-30 months after the EMR. Only one (2.2%) case of post procedure bleeding was observed.

CONCLUSION

EMR is a safe and efficious method for removal of flat, sessile adenomas, as well as early CRC. EMR is a routine endoscopic procedure in everyday practice of interventional endoscopist.

Colon cancer survival with herbal medicine and vitamins combined with standard therapy in a whole-systems approach: ten-year follow-up data analyzed with marginal structural models and propensity score methods

Although localized colon cancer is often successfully treated with surgery, advanced disease requires aggressive systemic therapy that has lower effectiveness. Approximately 30% to 75% of patients with colon cancer use complementary and alternative medicine (CAM), but there is limited formal evidence of survival efficacy. In a consecutive case series with 10-year follow-up of all colon cancer patients (n = 193) presenting at a San Francisco Bay-Area center for Chinese medicine (Pine Street Clinic, San Anselmo, CA), the authors compared survival in patients choosing short-term treatment lasting the duration of chemotherapy/radiotherapy with those continuing long-term. To put these data into the context of treatment responses seen in conventional medical practice, they also compared survival with Pan-Asian medicine + vitamins (PAM+V) with that of concurrent external controls from Kaiser Permanente Northern California and California Cancer Registries. Kaplan-Meier, traditional Cox regression, and more modern methods were used for causal inference-namely, propensity score and marginal structural models (MSMs), which have not been used before in studies of cancer survival and Chinese herbal medicine. PAM+V combined with conventional therapy, compared with conventional therapy alone, reduced the risk of death in stage I by 95%, stage II by 64%, stage III by 29%, and stage IV by 75%. There was no significant difference between short-term and long-term PAM+V. Combining PAM+V with conventional therapy improved survival, compared with conventional therapy alone, suggesting that prospective trials combining PAM+V with conventional therapy are justified.

Multicentric GISCoR Study "intensive clinical follow-up versus surgical radicalization after complete endoscopic polypectomy of a malignant adenoma" (SEC-GISCoR)

Colorectal cancer screening programs result in an early diagnosis of the disease. In 2007, 250 malignant polyps were identified in Lombardy, out of 1,329 screen-detected colorectal carcinomas. The Italian Group for Colorectal Cancer (GISCoR) promoted the multicentric study "Endoscopic Follow-up versus Surgical Radicalization of Malignant Polyps after Complete Endoscopic Polypectomy" (SEC-GISCoR). The protocol was a multicentric, prospective, observational, non-randomized study. It included patients diagnosed a colorectal malignant adenoma, after complete endoscopic removal. From November 2005 to September 2009, three participating centers enrolled 120 patients with malignant polyps after "complete" endoscopic polypectomy; malignant polyps were classified as "low risk" or "high risk". The study had two arms: "Intensive follow-up" (42 patients: 32 with low-risk and 10 with high-risk polyps) and "Surgical radicalization" (78 patients: 5 with low-risk and 73 with high-risk polyps). Data were collected using an online CRF. Overall, 37/120 polyps (30.8%) were low risk and 83/120 (69.2%) were high risk. 42 out of 120 patients (35%) were enrolled in the "clinical follow-up" arm, while 78/120 (65%) entered the surgery arm. In 15 cases, patients were not enrolled in the correct arm, according to the criteria agreed upon before starting the study. There still is a high incidence (11.5%) of pathological mismatches. No clinical event was reported in 2.9 years of follow-up. In conclusion, some differences emerged in the management of patients with malignant polyps among participating centers (p < 0.001), mismatches can be explained by high surgical risk or patient's choice. Only in 5 cases (4.2%), did data analysis not allow to exactly determine the reason for a choice different from protocol criteria. The availability of new risk factors and the evidence of pathological mismatches confirmed the need for future studies on this issue.

PDCD4 nuclear loss inversely correlates with miR-21 levels in colon carcinogenesis

Programmed cell death 4 (PDCD4) has recently been demonstrated to be a new tumor suppressor gene involved in colon carcinogenesis. PDCD4 immunohistochemical expression was assessed in 300 polypoid lesions of the colon mucosa (50 hyperplastic polyps [HP], 50 serrated adenomas [SA], 50 tubular adenomas with low-grade-intraepithelial neoplasia [LG-IEN], 50 tubular adenomas with high-grade-IEN [HG-IEN]), and in 50 colon adenocarcinomas (CRC). As normal controls, we considered 50 biopsy samples obtained from patients with irritable bowel syndrome (N). We further investigated PDCD4 messenger RNA (mRNA) levels by quantitative real-time polymerase chain reaction (PCR) in a different series of N, LG-IEN, HG-IEN, and CRC biopsy samples. miR-21 expression (an important PDCD4-expression regulator) was also determined by quantitative real-time PCR and in situ hybridization. Normal colocytes and HP featured strong PDCD4 nuclear immunostaining whereas a significantly lower PDCD4 nuclear expression was observed in dysplasia (low- and high-grade adenomas and SA) and invasive CRC. PDCD4 immunostaining and mRNA levels decreased significantly as the phenotypic changes occurring during colon carcinogenesis progressively increased (p < 0.001). As expected, miR-21 expression was significantly upregulated in preneoplastic/neoplastic samples, consistent with PDCD4 downregulation. These results consistently support the use of nuclear PDCD4 immunohistochemical downregulation as a novel biomarker for the diagnosis of dysplastic/neoplastic lesions in colon biopsy samples.

Quality assurance in colonoscopy for colorectal cancer diagnosis

Colonoscopy can prevent colorectal cancer, but its effectiveness is diminished by operator-dependent factors. Therefore, quality assurance programs should be implemented in all colonoscopy practices. Adherence to quality performance measures varies among different countries, and physicians seem reluctant to adopt them. We provide an overview of the existing guidelines for colonoscopy quality assurance, and a summary of the quality control initiatives in Belgium and the surrounding countries.

Black macular patches on parietal peritoneum and other extraintestinal sites from intraperitoneal spillage and spread of India ink from preoperative endoscopic tattooing: an endoscopic, surgical, gross pathologic, and microscopic study

BACKGROUND

Three cases, including one case report and two clinical images, have been reported of extraintestinal or peritoneal black maculae detected at laparoscopy after colonoscopic tattooing, presumably from intraperitoneal spillage of India ink during tattooing.

AIMS

Report three cases of inadvertent extraintestinal tattooing from endoscopic tattooing of intestinal lesions, provide histologic evidence for the presumed pathophysiology, and promulgate recommendations to prevent this complication.

METHODS

Three patients underwent endoscopic tattooing of intestinal lesions using India ink, surgery for lesion removal, and pathologic analysis.

RESULTS

Three patients had black macular patches or streaks identified intraoperatively at extraintestinal sites after endoscopic tattooing of intestinal lesions with India ink: (1) black patches on peritoneum 7 days after colonoscopic tattooing of cecal cancer, (2) black streaks on band connecting cecum to peritoneum 13 days after colonoscopic tattooing of cecal cancer, and (3) blackish band on jejunal mesentery 28 days after tattooing presumptive bleeding jejunal lesion. Pigmentation was detected at both injection and extraintestinal sites in all patients by (1) surgery, (2) gross pathology, and (3) microscopic examination demonstrating intracellular black pigmentation within mesothelial cells and macrophages. Special histologic stains were consistent with a carbon-based pigment, and inconsistent with iron or melanin as the pigment. The proposed mechanism is intraperitoneal India ink spillage from deep intestinal injection, as supported by histologic findings of subserosal pigment accumulation. An alternative histologic mechanism is migration of pigment-laden macrophages via lymphovascular channels.

CONCLUSIONS

Endoscopic injection of India ink using standard sclerotherapy needles can inadvertently tattoo extraintestinal sites in addition to tattooing the primary lesion. Despite its striking appearance, this intraoperative, gross, and microscopic finding is likely not pathologically significant, given its proposed pathophysiology. Surgical recognition of this entity is important, however, to prevent misinterpretation of findings as peritoneal melanoma, endometrial implants, infarcted mesentery, or tattooed cancer. This complication may be prevented by proper tattooing technique.

Negative prognostic factors in colorectal carcinoma: An analysis of 448 patients

BACKGROUND AND AIMS

Colorectal carcinoma (CRC) is the most frequent malignancy of the gastrointestinal tract. Prognostic researches are carried out for choosing the optimum therapy, evaluating therapy results and comparing multicentre results for better qualification in the therapy of the disease.

PATIENTS AND METHODS

In this study, 448 patients, whose surgery and follow-up was performed by the same correspondent surgeon between the years 1995 and 2003, were retrospectively analyzed.

RESULTS

Age, presence of comorbidity, weight loss, emergency admission, high serum CEA and CA 19-9 levels, neighboring organ invasion, operation type, major morbidity, tumor size and type, lymph node metastases, venous and perineural invasion, Dukes' classification and local recurrence and distant metastasis during follow-up are found to be significant negative factors affecting prognosis of the CRC patient.

CONCLUSION

Therapy results of the CRC are evaluated by survival times regardless of the therapy method selected for each individual. In our study we tried to find out negative prognostic factors by researching possible factors affecting disease free survival time for CRC. Since our understanding of factors that have an impact on prognosis increases, we are hoping to improve survival.

Invasive cancer in a diminutive rectal polyp amidst internal hemorrhoids detected by rectal retroflexion

A diminutive rectal polyp amidst internal hemorrhoids, detected by rectal retroflexion during colonoscopy, was shown to harbor invasive rectal adenocarcinoma by colonoscopic biopsy. Initially this lesion had appeared to be a relatively innocuous prominent anorectal mucosal fold and was recognized as a diminutive polyp only after careful rectal retroflexion during colonoscopy. This report emphasizes that lesions just above the anorectal junction with atypical endoscopic features for internal hemorrhoids should be carefully examined at rectal retroflexion and that polyps or suspicious lesions amidst internal hemorrhoids identified during colonoscopy should be snared or at least biopsied, even if small. This case report also illustrates how easily an early cancer in a diminutive colonic polyp can be missed when in difficult areas of colonoscopic inspection, such as behind a colonic fold or immediately above the anus.

Cap-assisted endoscopic mucosal resection for colorectal polyps

PURPOSE

Cap-assisted endoscopic mucosal resection has been used to treat superficial esophageal and gastric cancers. Efficacy data in the colon are limited. The aim of the study was to evaluate the safety and efficacy of this technique in the treatment of sessile polyps and lateral spreading tumors in the colorectum.

METHODS

Two-hundred and fifty-five consecutive patients with sessile polyps or lateral spreading tumors >or=20 mm were treated between January 2000 and December 2007.

RESULTS

A total of 146 sessile polyps and 136 lateral spreading tumors were treated with cap-assisted endoscopic mucosal resection. Complications occurred in 22 (8.6%) patients (5.5% in sessile polyps and 10.3% in lateral spreading tumors). Intraprocedural bleeding occurred in 21 (7%) of polypectomies (6% in sessile polyps and 10% in lateral spreading tumors); all were controlled endoscopically. Postcoagulation syndrome occurred in 1 patient with lateral spreading tumor. No perforation occurred. Invasive adenocarcinoma was found in 35 patients, of whom 15 underwent surgery. Endoscopic follow-up in 200 patients with 216 adenomas for a median of 12.1 months showed recurrence in 8 (4%) who were treated with resection and/or ablation.

CONCLUSIONS

Cap-assisted endoscopic mucosal resection is an effective treatment for sessile polyps and lateral spreading tumors. A disadvantage of the technique is that the resection is piecemeal. Close surveillance provides the opportunity for additional tissue ablation, when required, to achieve complete lesion removal.

The water jet deformation sign: a novel provocative colonoscopic maneuver to help diagnose an inverted colonic diverticulum

Colonoscopic differentiation of an inverted colonic diverticulum from a true colonic polyp is important because a true colonic polyp usually requires colonoscopic snare polypectomy or at least biopsy, whereas these maneuvers are contraindicated for an inverted diverticulum due to the risk of colonic perforation. Previously described diagnostic maneuvers to evert an inverted diverticulum include probing it with a closed biopsy forceps or intraluminal air insufflation during colonoscopy. On colonoscopy, a 59-year-old female had two intraluminal colonic projections. Probing these projections and using air insufflation failed to indent or evert them. Spraying these lesions with a water jet, however, flattened or partly everted them. This novel maneuver provided conclusive evidence that these intraluminal projections represented inverted diverticula. The proposed pathophysiology is that water pressure causes an inverted diverticulum to indent or evert due to its thin wall. The currently reported maneuver may be easier and safer than probing an inverted diverticulum with biopsy forceps and may prove a more reliable diagnostic maneuver than air insufflation.

Heterogeneity of colorectal adenomas, the serrated adenoma, and implications for screening and surveillance

Current algorithms for screening and surveillance for colon cancer are valuable, but may be limited by the underlying nature of the targeted neoplastic lesions. Although part of the success of adenoma removal relates to interruption of so-called “adenoma-carcinoma sequence”, an alternate serrated pathway to colon cancer may pose difficulties with the ultimate results achieved by traditional colonoscopic methods. The endpoint carcinoma in this unique pathway may be derived from a dysplastic serrated adenoma. These tend to be located primarily in the right colon, especially in females, and are frequently associated with co-existent colon cancer. Unfortunately, however, there are few, if any, other identifiable risk factors, including age or family history of colon polyps or colon cancer. Moreover, this alternate serrated pathway may itself also be quite biologically heterogeneous as reflected in sessile serrated adenomas (SSA) with virtually exclusive molecular signatures defined by the presence of either BRAF or KRAS mutations. Screening algorithms in the future may need to be modified and individualized, depending on new information that likely will emerge on the natural history of these biologically heterogeneous lesions that differs from traditional adenomatous polyps.