The Yield and Safety of Screening Colonoscopy in Patients Evaluated for Liver Transplantation

Poor risk-benefit ratio of gastrointestinal endoscopy for screening prior to heart or lung transplantation

BACKGROUND

Routine pre-transplant evaluations for heart or lung recipients often include upper and lower gastrointestinal endoscopies. However, given that these patients frequently have significant and multiple comorbidities, the risk-benefit ratio of endoscopy with sedation remains uncertain.

METHODS

We conducted a retrospective chart review of all patients who underwent esophagogastroduodenoscopy (EGD) and/or colonoscopy as part of the pre-transplant evaluation for heart (HTX) or lung transplantation (LuTX) at our center over a 10-year period. All procedures were performed with either anesthesiologist-assisted sedation or general anesthesia (72%) or physician-assisted sedation (28%). The primary outcomes included the prevalence of pre/neoplastic lesions and the rate of adverse events, classified according to the American Society of Gastrointestinal Endoscopy.

RESULTS

A total of 315 patients (70% male, median age 55 years) were included, with ASA grades 3 (31%) and 4 (69%). Of these, 90% underwent both EGD and colonoscopy. While no neoplasia or findings relevant to transplantation were detected on EGD, a single rectal malignant pedunculated polyp was identified and curatively removed via colonoscopy (G2 pT1 L0 V0 R0). The adenoma detection rate during colonoscopy was 25%, including a 7% rate of advanced adenomas, with six additional lesions (< 10 mm) exhibiting high-grade dysplasia. Conversely, severe adverse events occurred in 2.5% of cases, involving both cardiovascular and colonoscopy-related complications. These included two cases of severe hypotension and bradyarrhythmia requiring cardiovascular resuscitation, with one resulting in death (0.3% mortality). Additionally, one splenic rupture, two colonic perforations, and two cases of severe post-polypectomy bleeding were observed.

CONCLUSION

The routine requirement for upper and lower gastrointestinal endoscopy as a screening measure before heart or lung transplantation should be reconsidered due to its unfavorable risk-benefit profile. An individualized approach should be taken.

Development of a Risk Stratification Model for Pre-liver-Transplant Screening Colonoscopy

BACKGROUND AND AIMS

Colonoscopies are routinely obtained before liver transplantation, although their utility is a highly debated topic in the literature. We aimed to determine the risk factors in patients with decompensated cirrhosis (DC) for post-colonoscopy complications (PCC).

MATERIALS AND METHODS

We performed a single-center retrospective study of patients with DC undergoing colonoscopy as part of their pre-liver-transplant evaluation. The primary composite outcome was defined as a complication occurring within 30 days of the colonoscopy. Complications included acute renal failure, new or worsening ascites or hepatic encephalopathy, gastrointestinal bleeding, or any cardiopulmonary or infectious complication. Logistic regression analysis was utilized to derive a risk score in predicting the primary composite outcome.

RESULTS

The strongest predictors of post-colonoscopy complication were MELD-Na ≥21 [aOR 4.0026 ( P =0.0050)] and history of any infection in the 30 days before colonoscopy [aOR 8.4345 ( P =0.0093)]. The area under the receiver operating characteristic curve of the final model was 0.78. The predicted risk of any complication at the lowest quartile was 16.2% to 39.4%, and the observed risk was 30.6% (95% CI: 15.5-45.6%), while the predicted risk at the highest quartile was 71.9% to 97.1%, and the observed risk was 81.3% (95% CI: 67.7-95%).

CONCLUSION

In this cohort of patients with DC undergoing colonoscopy for pre-liver-transplant evaluation, a history of ascites, spontaneous bacterial peritonitis, and MELD-Na were found to be predictive of PCC. This risk score may help to predict PCC in patients with DC undergoing a pre-transplant colonoscopy. External validation is recommended.

Evaluation of ear, nose, and throat-screening in liver transplantation candidates: A retrospective cohort study

BACKGROUND

Patients with end-stage liver disease can be treated with a liver transplantation (LT). Before listing, candidates are subjected to a screening procedure according to the EASL Clinical Practice Guidelines for LT. In our hospital, this includes an ear, nose, and throat (ENT) examination, directed towards the identification of (asymptomatic) infections and head and neck malignancies.

METHODS

We retrospectively reviewed all ENT screening examinations in LT candidates from 2007 to 2022. The screening consisted of a visit to the ENT outpatient clinic combined with sinus radiography.

RESULTS

ENT screening was performed in 1099 patients. Sixty-one cases were identified, either diagnosed with an infection (n = 58, almost exclusively sinusitis) or a neoplasm (n = 3, of which two malignancies). With binary logistic regression, we could not identify significant risk factors for diagnosing sinusitis. 711 patients underwent LT. After LT, two patients developed a novel malignancy of the head and neck area, while 14 patients were diagnosed with sinusitis, two of the latter already showed opacification on sinus radiography during screening. Despite immunosuppressive drugs, no complicated sinusitis was observed.

CONCLUSION

Sinusitis or a neoplasm was diagnosed in almost 6% in a large cohort of LT candidates. Although almost a third of sinusitis patients were not treated accordingly, we did not observe any complicated sinusitis after LT. A more conservative approach to sinusitis may therefore be justified in LT candidates, especially in asymptomatic cases. At our institution, we aim to refer only those patients with specific ENT complaints .

Increased Risk of Advanced Colonic Adenomas and Timing of Surveillance Colonoscopy Following Solid Organ Transplantation

BACKGROUND

Detection and removal of colonic adenomatous polyps (CAP) decreases colorectal cancer (CRC) development, particularly with more or larger polyps or polyps with advanced villous/dysplastic histology. Immunosuppression following solid organ transplantation (SOT) may accelerate CAP development and progression compared to average-risk population but the benefit of earlier colonoscopic surveillance is unclear.

AIMS

Study the impact of maintenance immunosuppression post-SOT on developmental timing, multiplicity and pathological features of CAP, by measuring incidence of advanced CAP (villous histology, size ≥ 10 mm, ≥ 3 polyps, presence of dysplasia) post-SOT and the incidence of newly diagnosed CRC compared to average-risk age-matched population.

METHODS

Single-center retrospective cohort study of SOT recipients.

RESULTS

295 SOT recipients were included and were compared with 291 age-matched average-risk controls. The mean interval between screening and surveillance colonoscopies between SOT and control groups was 6.3 years vs 5.9 years (p = 0.13). Post-SOT maintenance immunosuppression mean duration averaged 59.9 months at surveillance colonoscopy. On surveillance examinations, SOT recipients exhibited more advanced (≥ 10 mm) adenomas compared to matched controls (9.2% vs. 3.8%, p = 0.034; adjusted OR 2.38; 95% CI 1.07-5.30).

CONCLUSION

SOT recipients appear at higher risk for developing advanced CAP, suggesting that earlier surveillance should be considered.

Gastrointestinal endoscopy in cirrhotic patient: Issues on the table

Patients with liver cirrhosis are fragile and present specific clinical hallmarks. When undergoing to gastrointestinal (GI) endoscopy, these subjects require an individual pre evaluation, taking into account: Level of haemostasis impairment, the individual risk of infection, the impact of sedation on hepatic encephalopathy and other factors. The overall assessment of liver function, employing common scoring systems, should be also assessed in the preprocedural phase. Beside some common general problems, regarding GI endoscopy in cirrhotic subjects, also specific issues are present for some frequent indications or procedures. For instance, despite an increased incidence of adenomas in cirrhosis, colon cancer screening remains suboptimal in subjects with this disease. Several studies in fact demonstrated liver cirrhosis as a negative factor for an adequate colon cleansing before colonoscopy. On the other hand, also the routine assessment of gastroesophageal varices during upper GI endoscopy presents some concern, since important inter-observer variability or incomplete description of endoscopic findings has been reported in some studies. In this review we discussed in details the most relevant issues that may be considered while performing general GI endoscopic practice, in patient with cirrhosis. For most of these issues there are no guidelines or clear indications. Moreover until now, few studies focused on these aspects. We believe that targeting these issues with corrective measures may be helpful to develop a tailored endoscopic approach for cirrhosis, in the future.

Low participation in preventative health measures in a cohort of liver transplant recipients: A cross-sectional analysis

BACKGROUND

Despite high rates of infection and malignancy post-solid organ transplant, there are little data on patient participation in preventative health care.

METHODS

We conducted a cross-sectional survey of post-liver transplant patients to evaluate insight into transplant-associated infective and neoplastic risks, and receipt of vaccination and cancer surveillance in accordance with Australian and local institution-specific guidelines. Descriptive analyses were used to assess characteristics potentially influencing adherence.

RESULTS

Of 219 patients surveyed, adherence to bowel cancer surveillance was significantly reduced in those distant from transplantation compared with those recently transplanted (95.8% if transplanted ≤ 5 years ago vs. 68.3% if transplanted > 5 years ago, P < .001). Skin cancer surveillance participation with annual physician-directed examination was low (42.9%), particularly in younger patients (29.5% in < 50yo vs. 48.1% in ≥ 50yo, P = .01), who were also less adherent to vaccination recommendations (72.1% in < 50yo vs. 87.3% in ≥ 50yo, P = .008).

CONCLUSIONS

This is the first analysis of preventative healthcare participation in a cohort of Australian liver transplant recipients, revealing concerning adherence to bowel and skin cancer surveillance recommendations. Major interventions to avoid preventable disease in this high-risk cohort are warranted.

Liver transplant recipients have an increased risk of developing colorectal adenomas: Results from a retrospective study

BACKGROUND

Liver transplant recipients have an increased incidence of malignancies, but it is unclear whether they have a higher risk of colorectal cancer.

AIM

To investigate whether liver transplant recipients have an increased risk of developing colorectal adenomas (a surrogate marker of colorectal cancer risk).

PATIENTS AND METHODS

One hundred thirty-nine liver transplant recipients (excluding primary sclerosing cholangitis) who underwent a colonoscopy and polypectomy before and after transplantation, and 367 nontransplanted patients who underwent a colonoscopy for colorectal cancer screening and a second colonoscopy later were retrospectively studied. The risks of incident colorectal adenomas and high-risk adenomas (advanced or multiple adenomas or carcinomas) were compared between both cohorts.

RESULTS

Incident colorectal adenomas were found in 40.3% of the transplanted patients and 30.0% of the nontransplanted patients (15.1% and 5.5%, respectively, had high-risk adenomas). After adjusting for age, sex, presence of adenomas in the baseline endoscopy, and interval between colonoscopies, transplant recipients showed a higher risk of developing colorectal adenomas (OR: 1.61; 95% CI: 1.05-2.47; p = .03) and high-risk adenomas (OR: 2.87; 95% CI: 1.46-5.65; p = .002).

CONCLUSIONS

Our results suggest that liver transplant recipients have an increased risk of developing colorectal adenomas and lesions with high risk of colorectal cancer.