Endoscopic Submucosal Dissection Decreases Additional Colorectal Resection for T1 Colorectal Cancer

Background

There are 3 methods of treating T1 colorectal cancer (T1 CRC), which include endoscopic resection, endoscopic resection followed by additional colorectal resection, and surgical resection. In this retrospective study, changes in the management of T1 CRC after introduction of endoscopic submucosal dissection (ESD) were investigated by comparison with the 10-year period before introduction of ESD.

Material/Methods

During a 20-year period from 1996 to 2015, 835 patients with T1 CRC were treated, including 331 patients before introduction of ESD (Group A) and 504 patients after introduction of ESD (Group B). Clinicopathological findings and treatment methods were compared between these 2 groups.

Results

As the initial treatment, endoscopic treatment was performed in 185 patients (55.9%) in Group A and 288 (57.1%) in Group B. In Group B, ESD was performed in 161 patients (55.9%), accounting for more than half of the T1 CRC patients receiving endoscopic treatment. In Groups A and B, observation after endoscopic resection was selected for 54.2% and 67.3% of T1a patients, respectively (p=0.04). A similar trend was noted for T1b patients, and there was no significant difference of the treatment approach. Among all T1 CRC patients, the percentage undergoing observation after endoscopic resection was significantly higher in Group B than in Group A (34.3% vs. 26.9%, p=0.02), and the percentage of patients undergoing additional colorectal resection was significantly lower in Group B (22.8% vs. 29.0%, p=0.04).

Conclusions

After introduction of ESD, it was performed in more than half of all patients with T1 CRC undergoing endoscopic treatment. The percentage of patients undergoing observation following endoscopic resection of T1 CRC increased after introduction of ESD.

Efficacy and Acceptability of 1 Liter of Polyethylene Glycol with Ascorbic Acid vs. 2 Liters of Polyethylene Glycol Plus Mosapride and Sennoside for Colonoscopy Preparation

BACKGROUND [color=black]Bowel preparation is an important factor for an optimal outcome of colonoscopy. Recently, polyethylene glycol (PEG) solution has been in common use for bowel cleansing for colonoscopy, but some patients are intolerant of PEG because of taste or volume. A low-volume PEG administered with ascorbic acid solution (PEG-Asc) was designed to improve tolerability, but the administration of this method is more complex than that with PEG alone. This study aimed to compare bowel cleansing efficacy, safety, and tolerability of 1 L PEG-Asc with a 2 L PEG preparation with use of sennosides and mosapride.[/color] MATERIAL AND METHODS [color=black]This was a prospective, single-center, non-inferiority trial that included 112 patients (PEG-Asc group, 68; PEG group, 44). The primary endpoint was the efficacy of colon cleansing assessed by endoscopists using a validated 4-point scale according to the Aronchick scale and was verified by a blinded investigator. Acceptability, tolerability, and adenoma detection rate (ADR) of these 2 regimens were secondary endpoints.[/color][color=black] [/color] RESULTS [color=black]We found no statistically significant differences between the groups in colon-cleansing efficacy or in the adenoma detection rate (ADR). Moreover, overall, patients significantly favored PEG-Asc over PEG, reflecting better acceptance of PEG-Asc. Additionally, more patients favored PEG-Asc over PEG for a hypothetical future colonoscopy. [/color] CONCLUSIONS [color=black]The alternate 1 L PEG-Asc regimen and standard 2 L PEG regimen were clinically equivalent with respect to cleansing efficacy, safety, and ADR, and more patients favored PEG-Asc than PEG. This alternate regimen may improve patient compliance and acceptance of surveillance colonoscopy.[/color].

Continuation of antithrombotic therapy may be associated with a high incidence of colonic post-polypectomy bleeding

BACKGROUND AND AIM

Post-polypectomy bleeding (PPB) is the most common complication of endoscopic procedures. To reduce the risk of thromboembolic incidents, Japanese guidelines for gastroenterological endoscopy were revised to indicate that antithrombotic agents were not to be discontinued for endoscopic treatment. However, carrying out endoscopic procedures under antithrombotic medication potentially increases the incidence of hemorrhagic complications. The present study investigated the impact of the revised guidelines on the frequency of complications after colonoscopic procedures.

METHODS

The surveillance period comprised the year before the initiation of the new guidelines (2012), which served as a control period, and 2 years after initiation of the new guidelines (2013 and 2014). During the control period, 3955 cases were examined colonoscopically and 1601 lesions were treated endoscopically. During the 2-year period under the new guidelines, 8749 colonoscopies and 3768 endoscopic treatments were carried out. Changes in treatment methods and rates of complications were compared.

RESULTS

PPB rate was not significantly different before and after the revision (0.87% vs 1.01%). With the new guidelines, PPB rates in antithrombotic non-users and users were 0.60% and 3.13%, respectively (OR 5.11, P = 0.000). Multivariable analysis showed that the risks for PPB were as follows: heparin bridging therapy (OR 6.34, P = 0.0002); low-dose aspirin (LDA) continuation (OR 5.30, P = 0.0079); and lesion size (OR 1.06, P < 0.0001).

CONCLUSION

The present study showed that the overall PPB rate under the new guidelines was not significantly higher when compared with the previous data obtained before the new guidelines were introduced.

Distinct endoscopic characteristics of sessile serrated adenoma/polyp with and without dysplasia/carcinoma

BACKGROUND AND AIMS

Sessile serrated adenoma/polyp (SSA/P) is a colorectal polyp that has malignant potential. However, the dysplastic components within an SSA/P can be difficult to detect. This study aimed to clarify the endoscopic characteristics of SSA/P with advanced histology.

METHODS

We examined 462 endoscopically or surgically resected lesions that were pathologically diagnosed as SSA/P, including 414 without and 41 with cytologic dysplasia, and 7 with invasive carcinoma. We retrospectively studied the clinicopathologic and endoscopic characteristics and performed pit pattern analysis.

RESULTS

A stepwise increase in the size of the SSA/P series was identified along with their dysplastic progression, although 19 of 48 (39.6%) SSA/Ps with dysplasia/carcinoma were ≤10 mm in size. Most lesions were covered with a mucus cap. Macroscopically, (semi)pedunculated morphology, double elevation, central depression, and reddishness were found more frequently in SSA/P with cytologic dysplasia and invasive carcinoma ([semi]pedunculated morphology, 17.1%/28.6%; double elevation, 63.4%/57.1%; central depression, 9.8%/28.6%; reddishness, 39.0%/85.7%) than in those without dysplasia (4.6%, 4.6%, 3.9%, and 3.4%, respectively). Furthermore, the presence of at least 1 of these 4 markers had high sensitivity (91.7%) for identifying the dysplasia/carcinoma within a SSA/P, with a specificity of 85.3%. In the pit pattern analysis, all SSA/Ps without dysplasia exhibited type II pit pattern only, whereas 94.4% of SSA/Ps with dysplasia/carcinoma showed type II in addition to type III_L, IV, V_I, or V_N pit patterns.

CONCLUSIONS

In an SSA/P series, endoscopic characteristics, including (semi)pedunculated morphology, double elevation, central depression, and reddishness, in addition to the use of magnifying endoscopy, may be useful to accurately diagnose advanced histology within an SSA/P.

Closure with clips to accelerate healing of mucosal defects caused by colorectal endoscopic submucosal dissection

BACKGROUND

Most mucosal defects that occur with endoscopic submucosal dissection (ESD) can be closed completely using endoscopic clips. However, benefits of such closure in wound healing are unknown. A randomized controlled study evaluated the efficacy of closure with clips compared with no closure.

METHOD

Twenty-eight patients who had undergone ESD were randomly divided into two groups: closure (n = 14) and non-closure groups (n = 14). In the closure group, the mucosal defect resulting from ESD was closed using endoscopic clips. Four weeks after ESD, defects in both groups were observed by colonoscopy. Efficacy was based on change in the area of the defect, percentage of complete healing in each group, and complications.

RESULT

Data were analyzed for 26 of the 28 patients (13, closure group; 13, non-closure group). All tumors were resected en bloc by ESD without bleeding or perforation. In the closure group, the area of the defect just after ESD was 677 ± 306 mm(2) (mean ± SD) as determined by the size of the removed lesion and had decreased to 2.17 ± 4.51 mm(2) at 4 weeks after ESD (reduction, 99.7 %), but in the non-closure group that area was 790 ± 221 mm(2) and had decreased to 27.42 ± 25.72 mm(2) at 4 weeks post-ESD (reduction, 96.2 %). The reduction rate was significantly higher in the closure than in the non-closure group (99.7 vs. 96.2 %, p = 0.010). Complete healing was 69.2 % in the closure group vs. 7.7 % in the non-closure group (p = 0.005). Multivariate analysis showed that closure of the mucosal defect (OR 24.029, 95 % CI 2.09-276.15, p = 0.011) was an independent factor associated with complete healing at 4 weeks after ESD. Delayed perforation or post-ESD bleeding was not observed in any participant.

CONCLUSION

Use of endoscopic clips for closure of defects after ESD is safe and efficacious in accelerating wound healing.

TRIAL REGISTRATION

UMIN-CTR UMIN000009112.

Prospective clinical trial of traction device-assisted endoscopic submucosal dissection of large superficial colorectal tumors using the S-O clip

BACKGROUND

Endoscopic submucosal dissection (ESD) allows en bloc resection of superficial colorectal tumors regardless of size. However, ESD is technically difficult, hazardous, and time consuming. New devices may help overcome these drawbacks. We focused on traction methods and designed a new traction device, the "S-O clip." Its main advantage is that it allows direct visualization of the cutting line during submucosal dissection. Moreover, it can be used at any location without withdrawing the endoscope. The purpose of this study was to evaluate the efficacy and safety of traction device-assisted ESD for large colorectal tumors using the S-O clip.

METHODS

Between August 2010 and December 2011, ESD was performed in 70 patients with a superficial colorectal tumor ≥20 mm in diameter in our department. Patients were randomized into two groups: 27 cases in the S-O clip-assisted ESD group and 23 cases in the conventional ESD group. Included in the analysis were patient's gender and age, tumor form, size, and location, rate of en bloc resection, procedure time, presence or absence of intraoperative perforation or delayed bleeding, and pathological findings. Subgroup analysis stratified by these factors and multivariate analyses were conducted.

RESULTS

In the S-O clip-assisted ESD group, all 27 tumors were resected en bloc without any complications. Although a micro perforation occurred in one patient in the conventional ESD group, further surgical treatment was not required. None of the other 22 cases in the conventional ESD group experienced complications. The mean procedure time for the S-O clip-assisted ESD group was significantly shorter than for the conventional ESD group (37.4 ± 32.6 vs. 67.1 ± 44.1 min, p = 0.03). No significant between-group differences were found for the other factors.

CONCLUSION

Our results demonstrated that S-O clip-assisted ESD is safe and fast for en bloc resection of large superficial colorectal tumors.

Frequent occurrence of fever in patients who have undergone endoscopic submucosal dissection for colorectal tumor, but bacteremia is not a significant cause

BACKGROUND

We examined the incidence of and factors associated with fever, as well as the frequency of bacteremia, in patients who had undergone endoscopic submucosal dissection (ESD) for colorectal tumor.

METHOD

A total of 199 patients (120 male and 79 female) were included. The patients were classified into two groups based on the body temperature on the day after ESD treatment: group A, body temperature <37 °C; and group B, body temperature ≥37 °C. The following factors were analyzed to determine their potential association with post-ESD fever: gender, age, tumor size, form, location, and presence or absence of intraoperative perforation. In addition, blood samples from 50 patients were obtained for blood culture and 16S rRNA gene analysis by polymerase chain reaction.

RESULTS

Group A included 106 patients (70 male and 36 female), with a median age of 63 years. Group B included 93 patients (50 male and 43 female), with a median age of 70 years. The incidence of post-ESD fever in the entire cohort was 46.7%. Univariate analysis based on comparison between groups A and B showed that the following factors were significantly associated with post-ESD fever: age [mean ± standard deviation (SD)], 64.5 ± 9.2 versus 68.5 ± 10.8 years, P = 0.006; and tumor size (mean ± SD) 30.6 ± 10.8 versus 39.1 ± 16.6 mm, P < 0.001. Logistic regression analysis for post-ESD fever also found that age {odds ratio 1.04 (95% CI [1.01-1.07], P = 0.009)} and lesion size {odds ratio 1.05 (95% CI [1.03-1.08], P = 0.0002)} were closely associated with post-ESD fever. Of the 50 patients who had blood samples cultured and 16S rRNA gene analyzed, bacteria in blood culture and the 16S rRNA gene were not detectable in any of the samples from the 50 patients.

CONCLUSIONS

This study indicated that older patients and patients with large tumors were more likely to develop post-ESD fever, but there was a low probability that bacteremia was the cause of fever.

Evaluation of new subclassification of type V(I) pit pattern for determining the depth and type of invasion of colorectal neoplasm

BACKGROUND

Colorectal neoplasms with a type V(I) pit pattern include various lesions, such as adenomas, intramucosal cancers, and submucosal carcinomas.

METHODS

We analyzed 96 colorectal neoplasms with a type V(I) pit pattern and identified six different variants: (1) unclear outline of the pit; (2) irregular margins of the pit; (3) narrowing of the pit; (4) ragged array of the pit; (5) high residual density of the pit; (6) abnormal branching of the pit. We examined the relationship between the appearance of each V(I) pit pattern and histology, including the depth of invasion.

RESULTS

In univariate logistic regression analysis the unclear outline, irregular margins, and narrowing of the pit were significantly associated with a submucosal (SM) invasion ≥1000 μm (P < 0.01). In multivariate logistic regression analysis, unclear outline of the pit was shown to be the only significant predictor of highly invasive submucosal cancer (odds ratio = 24.20, P < 0.0001). Regarding tumor morphology, the following were significantly associated with an SM invasion ≥1000 μm: in protruded type, ragged array (P = 0.022), irregular margins of the pit (P = 0.011), and unclear outline of the pit (P < 0.01); in flat type, irregular margins of the pit (P < 0.01) and unclear outline of the pit (P < 0.01); and in the depressed type, narrowing of the pit (P = 0.015) and unclear outline of the pit (P < 0.01).

CONCLUSIONS

Subclassification of the type V(I) pit pattern is useful for determining the depth of invasion of colorectal neoplasms.

[A case report of Ewing's sarcoma with a peripheral primitive neuroectodermal tumor (ES/pPNET) in the abdominal cavity]

In this report, we present a rare case of Ewing's sarcoma with a peripheral primitive neuroectodermal tumor (ES/pPNET) arising from the abdominal cavity in a 20-year-old woman. The patient complained of upper abdominal pain. Radiological imaging showed a 15-cm mass penetrating to the proxymal jejunum in the upper abdominal cavity and peritoneal disseminations. Immunohistochemical studies revealed that the tumor was ES/pPNET. Although the patient underwent radiation therapy, she died of the disease two months after diagnosis. ES/pPNET in the abdominal cavity is extremely rare and our case showed aggressive behavior and an unfortunate outcome.

Safety and efficacy of one-week triple therapy for eradicating Helicobacter pylori in children

BACKGROUND

Proton pump inhibitor-based eradication therapy of Helicobacter pylori has been widely studied in adults, but there have been only a few reports about this therapy in children. The purpose of this study was to investigate the safety and efficacy of 1-week triple therapy for eradication of H. pylori and ulcer healing in children.

PATIENTS AND METHODS

We prospectively studied 15 patients aged 2-17 years (5 with gastric ulcers, 8 with duodenal ulcers, and 2 with nodular gastritis alone). Three patients had H2 blocker-resistant duodenal ulcers. Patients received 0.75 mg/kg of lansoprazole b.i.d., 25 mg/kg of amoxicillin b.i.d., and 10 mg/kg of clarithromycin b.i.d. for 7 days. No additional therapy (including antisecretory drugs) was administered to any patients following eradication therapy. Patients underwent endoscopy to obtain antral biopsies (culture, urease test and histology) and to evaluate the mucosal status, and underwent a 13C-urea breath test before and 4-8 weeks after the completion of a 1-week course of therapy.

RESULTS

All patients received the full drug regimen. Endoscopy showed complete healing of ulcers in 12 of 13 patients with peptic ulcer disease (92%). H. pylori was eradicated in 13 of 15 patients (87%). Diarrhea and/or an altered taste sensation occurred in 5 patients (33%). There were no hematological or biochemical abnormalities related to therapy.

CONCLUSION

The 1-week triple therapy was safe and effective for eradicating H. pylori. The present study showed that ulcer healing in juveniles is closely associated with eradication of H. pylori, and that no additional therapy is required when H. pylori is eradicated. A shorter course of eradication therapy than 2 weeks may be suitable for children with H. pylori infection.