Endoscopic tattooing for colorectal lesions: impact on quality of care and patient outcomes

Impact of routine preoperative 18 FDG PET/CT on the surgical management of primary colorectal cancer

OBJECTIVES

Determine the usefulness of [18F]-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸ FDG-PET/CT) in the preoperative setting of colorectal cancer (CRC), assessing its impact on changes in management strategy.

METHODS

Retrospective study of CRC patients who underwent preoperative ¹⁸ FDG-PET/CT and CT staging scans in a single referral center. The agreement between ¹⁸ FDG-PET/CT, contrast-enhanced CT, and colonoscopy for the surgical location was compared using the κ coefficient. Maximum standardized uptake (SUV_max ) value was obtained. Univariate and multivariate analyses were conducted.

RESULTS

One hundred ninety-five patients were included. ¹⁸ FDG-PET/CT improved tumor localization in 84.6% (165/195) of cases (κ value 0.798, p < 0.001), thus correcting endoscopic errors 69.7% (30/43) of the time. In patients with incomplete colonoscopies, ¹⁸ FDG-PET/CT detected synchronous tumors in 2.5% (5/195) patients, overlooked by CT staging scans. Based on extracolonic ¹⁸ FDG-uptake, the second primary malignancy was diagnosed in 7(3.6%,7/195) patients and total accuracy for lymph node and distant metastasis was 66.1% and 98.4%, respectively. The treatment plan was altered in 30 (15.4%, 30/196) patients. There was a significant association between the SUV_max and tumor size (odds ratio [OR] 4.254, p = 0.003) and the depth of tumor invasion (OR 1.696, p = 0.026).

CONCLUSIONS

Based on its ability to aid in preoperative evaluation and definitively alter surgical treatment planning, ¹⁸ FDG-PET/CT should be further evaluated in primary CRC.

A single centre audit: repeat pre-operative colonoscopy

BACKGROUND

Repeat colonoscopy may be required for tumour localisation. The aim of the study is to explore the clinical settings it was used and benchmark the quality of initial colonoscopy against standardized guidelines for tumour localisation, tattooing and colonoscopy reporting amongst clinicians.

METHODS

A retrospective study from 2016 to 2021 has been performed on patients who underwent elective colorectal cancer resections at the Northern Hospital. Patient demographics, colonoscopic and operative details were retrieved from the Bi-National Colorectal Cancer Audit (BCCA) Registry database and hospital medical records.

PRIMARY OUTCOMES

changes in operative approach and delays to operation.

SECONDARY OUTCOMES

reasons for a repeat colonoscopy and complications from repeat colonoscopy.

RESULTS

A total of 339 patients were included in this study. 94 (28.6%) underwent a repeat colonoscopy. Re-scoping rate was 29.6% for surgeons, and 26.2% for non-operating endoscopists. Surgeons had a 5.9% localisation error rate, and non-operating endoscopist 6.95% (p = 0.673). Surgeons did not have a lower rate of repeat colonoscopy (p = 0.462). Repeat endoscopy was associated with a longer time to definitive operation (p < 0.001). No complications were associated with a repeat colonoscopy.

CONCLUSION

There was no difference in localisation error rates or repeat colonoscopy amongst surgeons (29.6%) and non-operating endoscopists (26.2%) (p = 0.462). This could be explained by the standardized endoscopy training in Australia governed by a common training board. Lack of tattooing at index colonoscopy and inadequate documentation often led to a repeat endoscopy, which was associated with a longer time to definitive operation. Standardized guidelines in tattooing of lesions and colonoscopy reporting should be implemented.

Large polyps: Pearls for the referring and receiving endoscopist

Polyps are precursors to colorectal cancer, the third most common cancer in the United States. Large polyps, i.e.,, those with a size ≥ 20 mm, are more likely to harbor cancer. Colonic polyps can be removed through various techniques, with the goal to completely resect and prevent colorectal cancer; however, the management of large polyps can be relatively complex and challenging. Such polyps are generally more difficult to remove en bloc with conventional methods, and depending on level of expertise, may consequently be resected piecemeal, leading to an increased rate of incomplete removal and thus polyp recurrence. To effectively manage large polyps, endoscopists should be able to: (1) Evaluate the polyp for characteristics which predict high difficulty of resection or incomplete removal; (2) Determine the optimal resection technique (e.g., snare polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection, etc.); and (3) Recognize when to refer to colleagues with greater expertise. This review covers important considerations in this regard for referring and receiving endoscopists and methods to best manage large colonic polyps.