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Zaffaroni G, Mannucci A, Koskenvuo L, de Lacy B, Maffioli A, Bisseling T, Half E, Cavestro GM, Valle L, Ryan N, Aretz S, Brown K, Buttitta F, Carneiro F, Claber O, Blanco-Colino R, Collard M, Crosbie E, Cunha M, Doulias T, Fleming C, Heinrich H, Hüneburg R, Metras J, Nagtegaal I, Negoi I, Nielsen M, Pellino G, Ricciardiello L, Sagir A, Sánchez-Guillén L, Seppälä TT, Siersema P, Striebeck B, Sampson JR, Latchford A, Parc Y, Burn J, Möslein G. Updated European guidelines for clinical management of familial adenomatous polyposis (FAP), MUTYH-associated polyposis (MAP), gastric adenocarcinoma, proximal polyposis of the stomach (GAPPS) and other rare adenomatous polyposis syndromes: a joint EHTG-ESCP revision. Br J Surg 2024; 111:znae070. [PMID: 38722804 PMCID: PMC11081080 DOI: 10.1093/bjs/znae070] [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] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/12/2024] [Accepted: 02/25/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Hereditary adenomatous polyposis syndromes, including familial adenomatous polyposis and other rare adenomatous polyposis syndromes, increase the lifetime risk of colorectal and other cancers. METHODS A team of 38 experts convened to update the 2008 European recommendations for the clinical management of patients with adenomatous polyposis syndromes. Additionally, other rare monogenic adenomatous polyposis syndromes were reviewed and added. Eighty-nine clinically relevant questions were answered after a systematic review of the existing literature with grading of the evidence according to Grading of Recommendations, Assessment, Development, and Evaluation methodology. Two levels of consensus were identified: consensus threshold (≥67% of voting guideline committee members voting either 'Strongly agree' or 'Agree' during the Delphi rounds) and high threshold (consensus ≥ 80%). RESULTS One hundred and forty statements reached a high level of consensus concerning the management of hereditary adenomatous polyposis syndromes. CONCLUSION These updated guidelines provide current, comprehensive, and evidence-based practical recommendations for the management of surveillance and treatment of familial adenomatous polyposis patients, encompassing additionally MUTYH-associated polyposis, gastric adenocarcinoma and proximal polyposis of the stomach and other recently identified polyposis syndromes based on pathogenic variants in other genes than APC or MUTYH. Due to the rarity of these diseases, patients should be managed at specialized centres.
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Affiliation(s)
- Gloria Zaffaroni
- Center for Hereditary Tumors, Bethesda Hospital, Duisburg, Germany
- Faculty of Medicine and Surgery, University of Milan, Milan, Italy
| | - Alessandro Mannucci
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Koskenvuo
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Borja de Lacy
- Department of Gastrointestinal Surgery, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Anna Maffioli
- Faculty of Medicine and Surgery, University of Milan, Milan, Italy
- Department of General Surgery, Sacco Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Tanya Bisseling
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Elizabeth Half
- Cancer Prevention and Hereditary GI Cancer Unit, Rambam Health Care Campus, Haifa, Israel
| | - Giulia Martina Cavestro
- Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Valle
- Hereditary Cancer Program, Catalan Institute of Oncology, Oncobell Program, IDIBELL, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain
| | - Neil Ryan
- The College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Stefan Aretz
- Institute of Human, Genetics, Medical Faculty, University of Bonn and National Center for Hereditary Tumour Syndromes, University Hospital Bonn, Bonn, Germany
| | - Karen Brown
- Leicester Cancer Research Centre, University of Leicester, Leicester, UK
| | - Francesco Buttitta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- IRCCS University Hospital of Bologna, Policlinico di Sant’Orsola, Bologna, Italy
| | - Fatima Carneiro
- Faculty of Medicine of Porto University, Centro Hospitalar Universitário de São João, Ipatimup, Porto, Portugal
| | - Oonagh Claber
- Department of Clinical Genetics, Northern Genetics Service, Newcastle upon Tyne, UK
| | - Ruth Blanco-Colino
- Department of Gastrointestinal Surgery, Vall d’Hebron University Hospital, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maxime Collard
- Department of Digestive Surgery, Hôpital Saint-Antoine, Sorbonne University, APHP, Paris, France
| | - Emma Crosbie
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Miguel Cunha
- Department of Surgery, Algarve Universitary Hospital Center, Colorectal SurgeryGroup, Portimao, Portugal
| | - Triantafyllos Doulias
- Department of Colorectal Surgery, Colchester Hospital, East Suffolk and North Essex NHS Foundation Trust, Colchester, UK
- Colorectal Surgery Department, Kettering Hospital, University Hospitals of Northamptonshire, Kettering, Northamptonshire, UK
- Department of Genetics and Genome Biology, Honorary Lecturer in the Leicester Cancer Research Centre, Leicester, UK
| | - Christina Fleming
- Department of Colorectal Surgery, University Hospital Limerick, Limerick, Ireland
| | - Henriette Heinrich
- Department for Gastroenterology and Hepatology, Clarunis Universitäres Bauchzentrum, Universitätsspital Basel, Basel, Switzerland
| | - Robert Hüneburg
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- National Center for Hereditary Tumour Syndromes, University Hospital Bonn, Bonn, Germany
| | - Julie Metras
- Department of Digestive Surgery, Hôpital Saint-Antoine, Sorbonne University, APHP, Paris, France
| | - Iris Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ionut Negoi
- Department of General Surgery, Carol Davila University of Medicine and Pharmacy Bucharest, Emergency Hospital of Bucharest, Bucharest, Romania
| | - Maartje Nielsen
- Clinical Genetics Department, Leiden University Medical Center, Leiden, The Netherlands
| | - Gianluca Pellino
- Department of Gastrointestinal Surgery, Vall d’Hebron University Hospital, Barcelona, Spain
- Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Luigi Ricciardiello
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- IRCCS University Hospital of Bologna, Policlinico di Sant’Orsola, Bologna, Italy
| | | | - Luis Sánchez-Guillén
- Department of Gastrointestinal Surgery, Elche General University Hospital, Elche, Alicante, Spain
- Miguel Hernández University, Elche, Spain
| | - Toni T Seppälä
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Applied Tumour Genomics Research Program, University of Helsinki, Helsinki, Finland
- Faculty of Medicine and Health Technology, University of Tampere and TAYS Cancer Centre, Tampere, Finland
- iCAN Precision Medicine Flagship, University of Helsinki, Helsinki, Finland
| | - Peter Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Julian R Sampson
- Institute of Medical Genetics, Division of Cancer and Genetics, Cardiff University School of Medicine, Cardiff, UK
| | - Andrew Latchford
- Polyposis Registry, St Mark’s Hospital, Harrow, UK
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Yann Parc
- Department of Digestive Surgery, Hôpital Saint-Antoine, Sorbonne University, APHP, Paris, France
| | - John Burn
- Newcastle University Translational and Clinical Research Institute, Centre for Life, Newcastle upon Tyne, UK
| | - Gabriela Möslein
- Center for Hereditary Tumors, Bethesda Hospital, Duisburg, Germany
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Aelvoet AS, Martin I, Cockburn J, Cabalit C, Cuthill V, Spalding D, Busch O, Bastiaansen BA, Clark SK, Dekker E, Latchford A. Outcomes following duodenectomy in patients with familial adenomatous polyposis. Endosc Int Open 2024; 12:E659-E665. [PMID: 38707599 PMCID: PMC11068438 DOI: 10.1055/a-2298-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/27/2024] [Indexed: 05/07/2024] Open
Abstract
Background and study aims Some patients with familial adenomatous polyposis (FAP) and extensive duodenal polyposis or cancer require total duodenectomy. Regular postoperative endoscopic surveillance of the remaining jejunum and stomach is recommended, but little is known about the outcomes after this surgery. Patients and methods Patients with FAP who underwent either pancreatoduodenectomy (PD) or pancreas-preserving total duodenectomy (PPTD) were identified at two expert centers. Data about postoperative endoscopic surveillance outcomes were collected, as well as survival outcomes. Results Overall, 119 patients (50% female) underwent duodenectomy (86 PD and 33 PPTD); 100 for benign duodenal polyposis and 19 for duodenal or ampullary cancer. Details of postoperative endoscopic surveillance were available for 88 patients (74%). During a median follow-up of 106 months, 36 patients (41%) were diagnosed with jejunal adenomas after duodenectomy, with a significantly higher proportion in patients who underwent PPTD compared with patients who underwent PD (log-rank, P < 0.01). Two patients developed jejunal cancer (2%). Twenty-six patients (30%) were diagnosed with a total of 66 gastric adenomas, of which 61% were located in the fundus/body and 39% in the antrum. Five patients (6%) developed gastric cancer after a median of 15 years (range 6-23 years), all but one within carpeting fundic gland polyposis. Patients who underwent surgery for cancer had worse survival than patients with benign disease and all but one patient with postoperative gastric/jejunal cancer died. Conclusions After duodenectomy in FAP, a considerable risk of developing adenomas and cancer in the stomach and jejunum exists with poor cancer prognosis, highlighting the need for close postoperative endoscopic surveillance.
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Affiliation(s)
- Arthur S. Aelvoet
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Isabel Martin
- Polyposis Registry, St Mark's Hospital, Harrow, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom Ireland
| | - James Cockburn
- Polyposis Registry, St Mark's Hospital, Harrow, United Kingdom
| | - Cherryl Cabalit
- Polyposis Registry, St Mark's Hospital, Harrow, United Kingdom
| | | | - Duncan Spalding
- Department of Surgery and Cancer, Imperial College, London, United Kingdom Ireland
| | - Olivier Busch
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Amsterdam UMC location, Amsterdam, the Netherlands
| | - Barbara A.J. Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Susan K. Clark
- Polyposis Registry, St Mark's Hospital, Harrow, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom Ireland
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Andrew Latchford
- Polyposis Registry, St Mark's Hospital, Harrow, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom Ireland
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Poylin VY, Shaffer VO, Felder SI, Goldstein LE, Goldberg JE, Kalady MF, Lightner AL, Feingold DL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Inherited Adenomatous Polyposis Syndromes. Dis Colon Rectum 2024; 67:213-227. [PMID: 37682806 DOI: 10.1097/dcr.0000000000003072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Affiliation(s)
- Vitaliy Y Poylin
- Division of Gastrointestinal and Oncologic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Virginia O Shaffer
- Department of Surgery, Emory University College of Medicine, Atlanta, Georgia
| | - Seth I Felder
- Department of Surgery, Moffit Cancer Center, Tampa, Florida
| | - Lindsey E Goldstein
- Division of General Surgery, North Florida/South Georgia Veteran's Health System, Gainesville, Florida
| | - Joel E Goldberg
- Division of General and Gastrointestinal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matthew F Kalady
- Division of Colon and Rectal Surgery, Ohio State University, Columbus, Ohio
| | - Amy L Lightner
- Department of Colorectal Surgery, Scripps Clinic, San Diego, California
| | - Daniel L Feingold
- Division of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati, Cincinnati, Ohio
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Nakahira H, Takeuchi Y, Shimamoto Y, Ishiguro S, Yunokizaki H, Ezoe Y, Fujisawa F, Ishihara R, Takayama T, Yoshida T, Mutoh M, Ishikawa H. Progression of duodenal neoplasia to advanced adenoma in patients with familial adenomatous polyposis. Hered Cancer Clin Pract 2023; 21:25. [PMID: 38012770 PMCID: PMC10683362 DOI: 10.1186/s13053-023-00264-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 10/03/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Patients with familial adenomatous polyposis (FAP) have a lifetime risk of developing duodenal adenomas approaching 100%, and the relative risk for duodenal cancer compared with the general population is high. We conducted a retrospective study to investigate the progression of non-ampullary duodenal adenomas (NADAs) and risk factors for advanced lesions in patients with FAP. METHODS Of 248 patients with 139 pedigrees at 2 institutes, we assessed 151 patients with 100 pedigrees with a pathogenic germline variant in the adenomatous polyposis coli gene, excluding mosaic variants. We evaluated the prevalence of NADAs in patients with FAP, the progression of these adenomas to advanced adenoma during the observation period, and the risk factors for the lifetime development of high-grade dysplasia (HGD), large (≥ 10 mm) duodenal adenomas, and Spiegelman stage IV. RESULTS During the median observation period of 7 years, the incidences of patients with NADAs, with more than 20 polyps, with polyps ≥ 10 mm, with HGD, and with stage IV at the last esophagogastroduodenoscopy were increased 1.6-fold, 1.7-fold, 5-fold, 22-fold, and 9-fold, respectively. Intramucosal cancer occurred in three patients (2%), but no patients developed invasive cancer during the observation period because we performed endoscopic intervention for advanced adenomas. Stage progression was observed in 71% of 113 patients. Stage IV was more common in women, patients with a history of colectomy, and those with a 3' side mutation in their adenomatous polyposis coli gene. CONCLUSIONS NADAs in patients with FAP frequently become exacerbated. Our findings suggest that patients with FAP who develop duodenal adenomas should be surveyed to prevent the development of duodenal cancer.
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Affiliation(s)
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka, Japan.
- Department of Genetic Oncology, Division of Hereditary Tumors, Osaka International Cancer Institute, Osaka, Japan.
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, 3-39-15, Showa-machi, 371-8511, Maebashi, Gunma, Japan.
| | | | | | | | | | - Fumie Fujisawa
- Department of Genetic Oncology, Division of Hereditary Tumors, Osaka International Cancer Institute, Osaka, Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka, Japan
| | - Tetsuji Takayama
- Department of Gastroenterology and Oncology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Japan
| | - Teruhiko Yoshida
- Department of Genetic Medicine and Services, National Cancer Center Hospital, Tokyo, Japan
| | - Michihiro Mutoh
- Department of Molecular-Targeting Cancer Prevention, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hideki Ishikawa
- Ishikawa Gastroenterology Clinic, Osaka, Japan
- Department of Molecular-Targeting Cancer Prevention, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Stone JK, Mehta NA, Singh H, El-Matary W, Bernstein CN. Endoscopic and chemopreventive management of familial adenomatous polyposis syndrome. Fam Cancer 2023; 22:413-422. [PMID: 37119510 DOI: 10.1007/s10689-023-00334-3] [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: 01/23/2023] [Accepted: 04/18/2023] [Indexed: 05/01/2023]
Abstract
Familial adenomatous polyposis (FAP) is an autosomal dominant syndrome predisposing affected individuals to gastrointestinal (GI) cancers through a high burden of polyposis. Colorectal cancer rates reach 100% by the age of 45, making early colectomy a mainstay of treatment. While most patients undergo colectomy at an early age, ongoing screening and surveillance of the upper gastrointestinal tract and rectal pouch must continue throughout adulthood. Endoscopic therapy of gastric, duodenal, ampullary and rectal pouch polyps is critical to reduce morbidity and cancer related mortality. Management of these lesions is not uniform, and is dependent on their location, size, histology, and risk of malignant potential. Medical therapies targeting pathways that reduce the malignant progression of pre-cancerous lesions have been studied for many years. While studies on the use of aspirin and non-steroidal anti-inflammatories (NSAIDs) in chemoprevention have shown encouraging results in Lynch syndrome and primary colorectal cancer, the potential benefits of these medications have not been duplicated in FAP cohorts. While data remains limited on chemoprevention in FAP, a number of randomized trials are currently underway examining targeted therapies with the potential to slow the progression of the disease. This review aims to provide an in-depth review of the literature on current endoscopic options and chemopreventive therapies targeting FAP. While the endoscopic management has robust data for its use, chemoprevention in FAP is still in its infancy. The complementary use of chemopreventive agents and endoscopic therapy for FAP patients is quickly becoming a growing and exciting area of research.
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Affiliation(s)
- J K Stone
- Section of Gastroenterology, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.
| | - N A Mehta
- Center for Interventional and Therapeutic Endoscopy, Digestive Diseases and Nutrition, Rush University Medical Center, Chicago, IL, USA
| | - H Singh
- Section of Gastroenterology, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Research Institute, CancerCare Manitoba, Winnipeg, MB, Canada
| | - W El-Matary
- Section of Pediatric Gastroenterology, Department of Pediatrics, Max Rady College of Medicine, Winnipeg, MB, Canada
| | - C N Bernstein
- Section of Gastroenterology, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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MEIRA-JÚNIOR JD, YOGOLARE GG, MAGALHÃES DDP, NAMUR GN, CAMPOS FG, SEGATELLI V, NAHAS SC, JUKEMURA J. PANCREATIC SOLID-PSEUDOPAPILLARY NEOPLASM IN PATIENTS WITH FAMILIAL ADENOMATOUS POLYPOSIS. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 35:e1718. [PMID: 36629695 PMCID: PMC9831633 DOI: 10.1590/0102-672020220002e1718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/15/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Solid pseudopapillary neoplasm of the pancreas is an uncommon pancreatic tumor, which is more frequent in young adult women. Familial adenomatous polyposis is a genetic condition associated with colorectal cancer that also increases the risk of developing other tumors as well. AIM The aim of this study was to discuss the association of familial adenomatous polyposis with solid pseudopapillary neoplasm of the pancreas, which is very rare. METHODS We report two cases of patients with familial adenomatous polyposis who developed solid pseudopapillary neoplasm of the pancreas of the pancreas and were submitted to laparoscopic pancreatic resections with splenic preservation (one male and one female). RESULTS ß-catenin and Wnt signaling pathways have been found to play an important role in the tumorigenesis of solid pseudopapillary neoplasm of the pancreas, and their constitutive activation due to adenomatous polyposis coli gene inactivation in familial adenomatous polyposis may explain the relationship between familial adenomatous polyposis and solid pseudopapillary neoplasm of the pancreas. CONCLUSION Colonic resection must be prioritized, and a minimally invasive approach is preferred to minimize the risk of developing desmoid tumor. Pancreatic resection usually does not require extensive lymphadenectomy for solid pseudopapillary neoplasm of the pancreas, and splenic preservation is feasible.
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Affiliation(s)
- José Donizeti MEIRA-JÚNIOR
- Universidade de São Paulo, Faculty of Medicine, University Hospital, Gastroenterology Department, Digestive Surgery Division – São Paulo (SP), Brazil
| | - Gustavo Gonçalves YOGOLARE
- Universidade de São Paulo, Faculty of Medicine, University Hospital, Gastroenterology Department, Digestive Surgery Division – São Paulo (SP), Brazil
| | - Daniel de Paiva MAGALHÃES
- Universidade de São Paulo, Faculty of Medicine, University Hospital, Gastroenterology Department, Digestive Surgery Division – São Paulo (SP), Brazil
| | - Guilherme Naccache NAMUR
- Universidade de São Paulo, Faculty of Medicine, University Hospital, Gastroenterology Department, Digestive Surgery Division – São Paulo (SP), Brazil
| | - Fabio Guilherme CAMPOS
- Universidade de São Paulo, Faculty of Medicine, University Hospital, Gastroenterology Department, Digestive Surgery Division – São Paulo (SP), Brazil
| | - Vanderlei SEGATELLI
- Universidade de São Paulo, Faculty of Medicine, University Hospital, Pathology Department – São Paulo (SP), Brasil
| | - Sergio Carlos NAHAS
- Universidade de São Paulo, Faculty of Medicine, University Hospital, Gastroenterology Department, Digestive Surgery Division – São Paulo (SP), Brazil
| | - Jose JUKEMURA
- Universidade de São Paulo, Faculty of Medicine, University Hospital, Gastroenterology Department, Digestive Surgery Division – São Paulo (SP), Brazil
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Endoscopic Surveillance and Treatment of Upper GI Tract Lesions in Patients with Familial Adenomatous Polyposis-A New Perspective on an Old Disease. Genes (Basel) 2022; 13:genes13122329. [PMID: 36553595 PMCID: PMC9777896 DOI: 10.3390/genes13122329] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/01/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022] Open
Abstract
Familial adenomatous polyposis (FAP) is an autosomal dominant disease caused by a germline mutation in the adenomatous polyposis coli (APC) gene. Patients with FAP develop up to thousands of colorectal adenomas as well as lesions in the upper GI tract. In FAP, the upper digestive lesions include gastric fundic gland polyps (FGPs), antrum adenomas, duodenal or small intestinal adenomas, and carcinoma. Patients, after colectomy, are still at significant risk for extracolonic malignancies. Advances in endoscope resolution and optical enhancement technologies allow endoscopists to provide assessments of benign and malignant polyps. For this reason, in the past decades, endoscopic resection techniques have become the first line of treatment in patients with polyps in the upper GI, whereby polyps and even early cancers can be successfully cured. In FAP patients, endoscopic ampullectomy appears to be a safe and effective way of treating patients with ampullary tumors. According to current indications, endoscopic retrograde cholangiopancreatography (ERCP) and stenting of the main pancreatic duct follow ampullectomy.
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Image-enhanced endoscopy for real-time differentiation between hyperplastic and fundic gland polyps in the stomach. Indian J Gastroenterol 2022; 41:599-609. [PMID: 36562941 DOI: 10.1007/s12664-022-01278-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 06/25/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Fundic gland polyps (FGP) of stomach are benign, while some hyperplastic polyps (HP) may harbor dysplasia or malignancy. Conventional white light endoscopy (WLE) cannot reliably distinguish FGP from HP. We investigated the role of image-enhanced endoscopy in differentiating FGP from HP. METHODS Patients with gastric polyps were recruited prospectively. The characteristics of the polyps were assessed using WLE and magnification narrow band imaging (mNBI). The microsurface, intervening space (IS), and microvascular (V) features of polyps were evaluated on mNBI. The pattern characteristic of FGP and HP were determined. Histopathology of polyps was the gold standard for diagnosis. Finally, in the validation phase, five endoscopists applied the characteristic features identified in this study to predict the type of gastric polyp and their performance was assessed. RESULTS Forty-five patients with a total of 70 gastric polyps (HP-46, FGP-24) were included in this study. On mNBI, the pattern characteristic of HP included peripheral curved type of white structures forming large circular/villous loops (microsurface), enlarged intervening space, and microvessels appearing as dark patches in the intervening space (p<0.001 vs. FGP). These were noted in 95.7% HP. In contrast, 95.8% FGP had a pattern characterized by dotted/elliptical/tubular white structures (microsurface), normal width of intervening space, and microvessels surrounding the white structures in a network pattern. This IS-V pattern classification had an accuracy of >90% in the validation phase with intra-class correlation coefficient of 0.95. The accuracy of mNBI was higher than WLE (97.1% vs. 67%) in predicting the type of gastric polyp. CONCLUSIONS Image-enhanced endoscopy with mNBI (IS-V pattern) performs very well in differentiating HP from FGP.
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Novel Endoscopic Polypectomy Surveillance Technique for Fundic Gland Polyps in Familial Adenomatous Polyposis Can Improve Early Detection of Dysplasia and Gastric Cancer. Am J Gastroenterol 2022; 117:1246-1254. [PMID: 35584332 DOI: 10.14309/ajg.0000000000001833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 05/16/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Fundic gland polyps (FGPs) are commonly found in patients with familial adenomatous polyposis (FAP) and are considered benign. Biopsies are not routinely performed, and conventional forceps may be time-consuming and/or yield nonrepresentative histology. The purpose of this study was to evaluate the role of a novel endoscopic polypectomy surveillance (EPS), a large volume cold-snare polypectomy technique of random FGPs, in the incidence of dysplasia and gastric cancer (GC) in FAP. METHODS This is a retrospective longitudinal cohort of patients with FAP referred to a tertiary care center for duodenal adenoma surveillance and who underwent EPS of FGPs between 2001 and 2019. Demographic, endoscopic, and clinicopathologic information was reviewed. RESULTS Thirty-five patients with FAP were identified at initial endoscopy by the mean age of 43.4 years (±12.8). One hundred thirteen surveillance endoscopies were performed in total using EPS. Dysplasia of FGPs was present on initial esophagogastroduodenoscopy in 7 patients (20%), and 13 additional patients (46.4%) progressed to low-grade dysplasia. Three patients (15%) who subsequently had progression to GC were found to have signet ring cell cancer within the foci of FGPs through EPS. One patient presented as metastatic GC. Progression from nondysplastic FGP to low-grade dysplasia occurred over 63 months (±46.3) with further progression to GC over 34 months (±8.5). Endoscopic risk factors for cancer were polyps >10 mm in size ( P < 0.001) and carpeting of polyps ( P < 0.001). The 5-year cumulative incidence of developing dysplasia was 35.7%. DISCUSSION We identified that the incidence of dysplasia and GC is higher than previously reported in patients with FAP. Our study used a novel EPS technique and was able to identify GC within the foci of FGPs. Upper endoscopic guidelines should include a more rigorous sampling method for FGPs, such as EPS, to optimize early detection of dysplasia and GC.
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Mankaney G, Cruise M, Burke CA. Finding the needle in a haystack: approach to detection of high-risk gastric lesions in familial adenomatous polyposis. Gastrointest Endosc 2021; 94:1043-1045. [PMID: 34598775 DOI: 10.1016/j.gie.2021.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/14/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Gautam Mankaney
- Department of Gastroenterology and Hepatology, Virginia Mason Franciscan Health, Seattle, Washington
| | - Michael Cruise
- Pathology and Laboratory Medicine Institute, Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Colorectal Surgery, Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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11
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Stone JK, Bernstein CN, Singh H, El-Matary W. Prevalence of Gastroduodenal Polyps in Children With Familial Adenomatous Polyposis. J Can Assoc Gastroenterol 2021; 4:e101-e109. [PMID: 34617007 PMCID: PMC8489522 DOI: 10.1093/jcag/gwaa040] [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: 05/05/2020] [Accepted: 11/16/2020] [Indexed: 11/16/2022] Open
Abstract
Objective To assess the prevalence of upper gastrointestinal adenomatous polyps in a cohort of pediatric familial adenomatous polyposis (FAP) patients to determine if early screening is warranted. Study Design All 11 pediatric FAP patients diagnosed in Manitoba between January 2012 and December 2019 were recruited. Patient records were examined and data on age of diagnosis, gene mutation, age of first screening endoscopy, number of endoscopies, number of gastric and colonic polyps, associated pathology, medications, symptoms and FAP-related surgeries were extracted and descriptive statistics reported. Results A total of 11 children were diagnosed with FAP over the study period with a mean age at diagnosis of 6.3 ± 3.2 years with 72.3% males and median follow-up of 4.8 years. The mean age at first gastroscopy was 10.9 ± 2.9 years and 10.8 ± 3.0 years at colonoscopy. Eight patients (72%) had upper gastrointestinal polyps, with adenomatous changes seen in seven of them on pathology. No patients had invasive carcinoma or high-grade dysplasia. All patients developed tubular adenomas on colorectal polyp pathology. Four (36%) patients underwent surgical colectomy. Conclusions Early-onset upper gastrointestinal adenomatous polyps in a pediatric FAP are common. Our study provides further data to support consideration of further, large-scale research into the benefit of early endoscopic screening for upper gastrointestinal malignancy in FAP patients.
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Affiliation(s)
- James K Stone
- Department of Internal Medicine, Section of Gastroenterology, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada.,IBD Clinical and Research Center, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles N Bernstein
- Department of Internal Medicine, Section of Gastroenterology, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada.,IBD Clinical and Research Center, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Harminder Singh
- Department of Internal Medicine, Section of Gastroenterology, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada.,IBD Clinical and Research Center, University of Manitoba, Winnipeg, Manitoba, Canada.,Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - Wael El-Matary
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
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12
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Noh JH, Song EM, Ahn JY, Yang DH, Lee W, Hong J, Kim A, Na HK, Lee JH, Jung KW, Kim DH, Choi KD, Song HJ, Lee GH, Jung HY. Prevalence and endoscopic treatment outcomes of upper gastrointestinal neoplasms in familial adenomatous polyposis. Surg Endosc 2021; 36:1310-1319. [PMID: 33709227 DOI: 10.1007/s00464-021-08406-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although upper gastrointestinal (GI) neoplasms are not rare in patients with familial adenomatous polyposis (FAP), few studies have focused on them and the long-term outcomes of their treatment by endoscopy. Therefore, we aimed to investigate the prevalence and endoscopic treatment outcomes of upper GI neoplasms in patients with FAP. METHODS Among 215 patients diagnosed with FAP between January 1991 and December 2019, 208 who underwent esophagogastroduodenoscopy were eligible. The clinical features and endoscopic treatment outcomes of upper GI neoplasms were retrospectively investigated and analyzed. RESULTS Among the enrolled patients, 113 (54.3%) had one or more upper GI neoplasms: gastric adenoma (n = 34), gastric cancer (n = 7), nonampullary duodenal adenoma (n = 86), and ampullary adenoma (n = 53). Among patients with gastric neoplasms (n = 37), 24 (64.9%) underwent treatment (endoscopic treatment: 22, surgery: 2). No tumor-related mortality occurred during median follow-up of 106 months (interquartile range [IQR] 63-174). Endoscopic treatment was performed in 47 (54.7%) of 86 patients with nonampullary duodenal adenoma and in 32 (60.4%) of 53 patients with ampullary adenoma. No patient underwent surgery for duodenal neoplasms, and no tumor-related mortality occurred during median follow-up of 88 months (IQR 42-145). The proportion of patients with increased Spigelman stage at 2 years after the initial diagnosis or treatment was significantly higher in untreated group than in the group treated for duodenal neoplasms (27.3% vs. 0.0%, p = 0.001). CONCLUSION Endoscopic surveillance in FAP patients is important for the detection and treatment of upper GI neoplasms in early stage. In particular, endoscopic therapy for duodenal neoplasms can reduce the severity of duodenal polyposis.
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Affiliation(s)
- Jin Hee Noh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Mi Song
- Department of Gastroenterology, Ewha Womans University Medical Center, Seoul, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Woochang Lee
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jinyoung Hong
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Aram Kim
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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13
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Tanabe H, Moriichi K, Takahashi K, Ono Y, Kobayashi Y, Murakami Y, Iwama T, Kunogi T, Sasaki T, Ando K, Ueno N, Kashima S, Takei H, Mizukami Y, Fujiya M, Okumura T. Genetic alteration of colorectal adenoma-carcinoma sequence among gastric adenocarcinoma and dysplastic lesions in a patient with attenuated familial adenomatous polyposis. Mol Genet Genomic Med 2020; 8:e1348. [PMID: 32543103 PMCID: PMC7507424 DOI: 10.1002/mgg3.1348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 12/25/2022] Open
Abstract
Background Familial adenomatous polyposis (FAP) is characterized by colorectal polyposis and adenocarcinoma that is frequently accompanied by extracolonic neoplasm. The risk of gastric carcinoma is increasing in Western FAP patients as well as Asian patients. Methods We report the case of an FAP patient with fundic gland polyposis who developed gastric adenocarcinoma and metachronous pyloric gland adenomas. These tumors were endoscopically resected, and immunohistochemistry with gastric mucin (i.e., MUC6, MUC5AC) showed that the tumors belonged to the gastric subtype. Somatic mutation profiles were determined by target amplicon sequencing using a next‐generation sequencer. Results Germline APC variant c.5782delC was found by direct sequencing and somatic KRAS mutations in these tumors were identified by next‐generation sequencing. Different KRAS mutation alleles (KRAS p.Gly12Ala, p.Gly12Arg, and p.Gly12Asp) indicated these dysplastic lesions developed from a distinct origin in fundic gland polyposis. Sequential mutations of the APC and KRAS were judged—based on a database search—to be characteristic of the adenoma‐carcinoma sequence in colorectal carcinogenesis. Conclusion The colonic adenoma‐carcinoma sequence among gastric adenocarcinoma and dysplastic lesions was indicated in FAP‐associated gastric carcinogenesis.
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Affiliation(s)
- Hiroki Tanabe
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Kentaro Moriichi
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Keitaro Takahashi
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yusuke Ono
- Institute of Biomedical Research, Sapporo-Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan
| | - Yu Kobayashi
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yuki Murakami
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Takuya Iwama
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Takehito Kunogi
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Takahiro Sasaki
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Katsuyoshi Ando
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Nobuhiro Ueno
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Shin Kashima
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Hidehiro Takei
- Department of Diagnostic Pathology, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yusuke Mizukami
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan.,Institute of Biomedical Research, Sapporo-Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan
| | - Mikihiro Fujiya
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Toshikatsu Okumura
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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14
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Bollo J, Sarria S, Martinez C, Ramon y Cajal T, Hernandez P, Carrillo E, Sacoto D, Castillo JC, Sanchez A, Fernandez- Ananin S, Balague C, Targarona E. Implications of Bariatric Surgery in Patients with Familial Adenomatous Polyposis Requiring Proctocolectomy with Ileal Pouch Anal Anastomosis. Obes Surg 2020; 30:4609-4611. [DOI: 10.1007/s11695-020-04716-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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15
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Babaya A, Yamano T, Matsubara T, Takenaka Y, Song J, Kimura K, Yasuhara M, Kataoka K, Beppu N, Uchino M, Ikeda M, Ikeuchi H, Matsubara N, Tamura K, Tomita N. Long-term clinical outcomes and follow-up status in Japanese patients with familial adenomatous polyposis after radical surgery: a descriptive, retrospective cohort study from a single institute. Int J Colorectal Dis 2020; 35:675-684. [PMID: 32034491 DOI: 10.1007/s00384-020-03524-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Data on long-term outcomes of familial adenomatous polyposis (FAP) are unclear in Japan because a nationwide registry system is lacking. We assessed overall survival, incidence of neoplasms, fecal incontinence, and postoperative follow-up status of patients with FAP treated surgically in our hospital. METHODS In total, 154 patients with FAP who underwent radical surgery from 1981 to 2017 in our department were available for the questionnaire. Sixty-five patients, 36 of whom were followed at our hospital, were assessed using clinical records and the questionnaire. RESULTS The median follow-up time was 187 months (interquartile range, 93.5-296 months). The median age at surgery was 36 years (range, 12-69 years). The 5-, 10-, 15-, and 20-year overall survival rate was 100%, 98%, 95%, and 89%, respectively. All five deaths were caused by diseases other than colorectal cancer. FAP-related neoplasms comprised 23 colorectal cancers, five duodenal cancers, three gastric cancers, five thyroid cancers, two ileal pouch cancers, and nine desmoid tumors. The incidence of desmoid tumors was significantly associated with the operation date. The duration from radical surgery to neoplasm onset significantly differed by neoplasm type. Forty-five of 54 patients (excluding those who died or underwent ileostomy) developed fecal incontinence (median Wexner score of 8). Surgical procedures involving hand-sewn sutures with rectal mucosal stripping were significantly associated with fecal incontinence and the Wexner score. Fifty-eight of the 60 surviving patients underwent follow-up examinations. CONCLUSION Overall survival was favorable. Fecal incontinence depended on the surgical procedures. Most patients continued to receive follow-up examinations. TRIAL REGISTRATION No. 3112 by Institutional Review Board of Hyogo College of Medicine.
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Affiliation(s)
- Akihito Babaya
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Tomoki Yamano
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.
| | - Takaaki Matsubara
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Yuya Takenaka
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Jihyung Song
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Kei Kimura
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Michiko Yasuhara
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Kozo Kataoka
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Naohito Beppu
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Motoi Uchino
- Division of Surgery, Department of Inflammatory Bowel Disease, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Masataka Ikeda
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Hiroki Ikeuchi
- Division of Surgery, Department of Inflammatory Bowel Disease, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Nagahide Matsubara
- Department of Surgery, Amagasaki Chuo Hospital, 1-21-1 Shioe, Amagasaki, Hyogo, 660-0808, Japan
| | - Kazuo Tamura
- Department of Life Science, Faculty of Science and Engineering, Kindai University, 3-4-1 Kowakae,, Higashiosaka, Osaka, 577-8502, Japan
| | - Naohiro Tomita
- Division of Lower Gastrointestinal Surgery, Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
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