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Meulen LWT, Bogie RMM, Siersema PD, Winkens B, Vlug MS, Wolfhagen FHJ, Baven-Pronk M, van der Voorn M, Schwartz MP, Vogelaar L, de Vos Tot Nederveen Cappel WH, Seerden TCJ, Hazen WL, Schrauwen RWM, Alvarez Herrero L, Schreuder RMM, van Nunen AB, Stoop E, de Bruin GJ, Bos P, Marsman WA, Kuiper E, de Bièvre M, Alderlieste YA, Roomer R, Groen J, Bargeman M, van Leerdam ME, Roberts-Bos L, Boersma F, Thurnau K, de Vries RS, Ramaker JM, Vleggaar FP, de Ridder RJ, Pellisé M, Bourke MJ, Masclee AAM, Moons LMG. Standardised training for endoscopic mucosal resection of large non-pedunculated colorectal polyps to reduce recurrence (*STAR-LNPCP study): a multicentre cluster randomised trial. Gut 2024; 73:741-750. [PMID: 38216328 DOI: 10.1136/gutjnl-2023-330020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 12/11/2023] [Indexed: 01/14/2024]
Abstract
OBJECTIVE Endoscopic mucosal resection (EMR) is the preferred treatment for non-invasive large (≥20 mm) non-pedunculated colorectal polyps (LNPCPs) but is associated with an early recurrence rate of up to 30%. We evaluated whether standardised EMR training could reduce recurrence rates in Dutch community hospitals. DESIGN In this multicentre cluster randomised trial, 59 endoscopists from 30 hospitals were randomly assigned to the intervention group (e-learning and 2-day training including hands-on session) or control group. From April 2019 to August 2021, all consecutive EMR-treated LNPCPs were included. Primary endpoint was recurrence rate after 6 months. RESULTS A total of 1412 LNPCPs were included; 699 in the intervention group and 713 in the control group (median size 30 mm vs 30 mm, 45% vs 52% size, morphology, site and access (SMSA) score IV, 64% vs 64% proximal location). Recurrence rates were lower in the intervention group compared with controls (13% vs 25%, OR 0.43; 95% CI 0.23 to 0.78; p=0.005) with similar complication rates (8% vs 9%, OR 0.93; 95% CI 0.64 to 1.36; p=0.720). Recurrences were more often unifocal in the intervention group (92% vs 76%; p=0.006). In sensitivity analysis, the benefit of the intervention on recurrence rate was only observed in the 20-40 mm LNPCPs (5% vs 20% in 20-29 mm, p=0.001; 10% vs 21% in 30-39 mm, p=0.013) but less evident in ≥40 mm LNPCPs (24% vs 31%; p=0.151). In a post hoc analysis, the training effect was maintained in the study group, while in the control group the recurrence rate remained high. CONCLUSION A compact standardised EMR training for LNPCPs significantly reduced recurrences in community hospitals. This strongly argues for a national dedicated training programme for endoscopists performing EMR of ≥20 mm LNPCPs. Interestingly, in sensitivity analysis, this benefit was limited for LNPCPs ≥40 mm. TRIAL REGISTRATION NUMBER NTR7477.
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Affiliation(s)
- Lonne W T Meulen
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Roel M M Bogie
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands
- CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Marije S Vlug
- Department of Gastroenterology and Hepatology, Dijklander Hospital, Hoorn, The Netherlands
| | - Frank H J Wolfhagen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Martine Baven-Pronk
- Department of Gastroenterology and Hepatology, Groene Hart Hospital, Gouda, The Netherlands
| | - Michael van der Voorn
- Department of Gastroenterology and Hepatology, Haga Hospital, Den Haag, The Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Centre, Amersfoort, The Netherlands
| | - Lauran Vogelaar
- Department of Gastroenterology and Hepatology, Diakonessenhuis, Utrecht, The Netherlands
| | | | - Tom C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Ruud W M Schrauwen
- Department of Gastroenterology and Hepatology, Bernhoven, Uden, The Netherlands
| | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Annick B van Nunen
- Department of Gastroenterology and Hepatology, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Esther Stoop
- Department of Gastroenterology and Hepatology, Haaglanden Medical Centre, Den Haag, The Netherlands
| | - Gijs J de Bruin
- Department of Gastroenterology and Hepatology, Tergooi Hospital, Hilversum, The Netherlands
| | - Philip Bos
- Department of Gastroenterology and Hepatology, Hospital Gelderse Vallei, Ede, The Netherlands
| | - Willem A Marsman
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Edith Kuiper
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Marc de Bièvre
- Department of Gastroenterology and Hepatology, VieCuri Medical Centre, Venlo, The Netherlands
| | - Yasser A Alderlieste
- Department of Gastroenterology and Hepatology, Rivas Zorggroep, Gorinchem, The Netherlands
| | - Robert Roomer
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - John Groen
- Department of Gastroenterology and Hepatology, Sint Jansdal Hospital, Harderwijk, The Netherlands
| | - Marloes Bargeman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Monique E van Leerdam
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Linda Roberts-Bos
- Department of Gastroenterology and Hepatology, Laurentius Hospital, Roermond, The Netherlands
| | - Femke Boersma
- Department of Gastroenterology and Hepatology, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Karsten Thurnau
- Department of Gastroenterology and Hepatology, Hospital group Twente, Almelo, The Netherlands
| | - Roland S de Vries
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, The Netherlands
| | - Jos M Ramaker
- Department of Gastroenterology and Hepatology, Elkerliek Hospital, Helmond, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Rogier J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - María Pellisé
- Department of Gastroenterology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Ad A M Masclee
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
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Haghbin H, Zakirkhodjaev N, Fatima R, Kamal F, Aziz M. Efficacy and Safety of Thermal Ablation after Endoscopic Mucosal Resection: A Systematic Review and Network Meta-Analysis. J Clin Med 2024; 13:1298. [PMID: 38592137 PMCID: PMC10932371 DOI: 10.3390/jcm13051298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/20/2024] [Accepted: 02/23/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: Large colonic polyps during colonoscopy can be managed by Endoscopic mucosal resection (EMR). To decrease the polyp recurrence rate, thermal ablation methods like argon plasma coagulation (APC) and snare tip soft coagulation (STSC) have been introduced. We performed this network meta-analysis to assess the efficacy and safety of these modalities. (2) Methods: We performed a comprehensive literature review, through 5 January 2024, of databases including Embase, PubMed, SciELO, KCI, Cochrane Central, and Web of Science. Using a random effects model, we conducted a frequentist approach network meta-analysis. The risk ratio (RR) with 95% confidence interval (CI) was calculated. Safety and efficacy endpoints including rates of recurrence, bleeding, perforation, and post polypectomy syndrome were compared. (3) Results: Our search yielded a total of 13 studies with 2686 patients. Compared to placebo, both APC (RR: 0.33 CI: 0.20-0.54, p < 0.01) and STSC (RR: 0.27, CI: 0.21-0.34, p < 0.01) showed decreased recurrence rates. On ranking, STSC showed the lowest recurrence rate, followed by APC and placebo. Regarding individual adverse events, there was no statistically significant difference between either of the thermal ablation methods and placebo. (4) Conclusions: We demonstrated the efficacy and safety of thermal ablation after EMR for decreasing recurrence of adenoma.
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Affiliation(s)
- Hossein Haghbin
- Division of Gastroenterology, Ascension Providence Hospital, Southfield, MI 48075, USA
| | - Nuruddinkhodja Zakirkhodjaev
- Division of Occupational and Environmental Medicine, The University of Texas Health Science Center at Houston, Houston, TX 77021, USA;
| | - Rawish Fatima
- Division of Rheumatology, University of Toledo, Toledo, OH 43606, USA;
| | - Faisal Kamal
- Division of Gastroenterology, Thomas Jefferson University, Philadelphia, PA 19144, USA;
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, Bon Secours Mercy Health, Toledo, OH 43608, USA;
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3
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Qi H, Wang Z, Shen F, Yu W, Duan S, Li X, Huang X. Wound infection prevention strategies in colorectal endoscopic mucosal resection: A meta-analysis of prophylactic measures. Int Wound J 2024; 21:e14544. [PMID: 38272812 PMCID: PMC10789545 DOI: 10.1111/iwj.14544] [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: 11/03/2023] [Revised: 11/20/2023] [Accepted: 11/23/2023] [Indexed: 01/27/2024] Open
Abstract
Colorectal endoscopic mucosal resection (EMR) is associated with the risk of postoperative wound infections, prompting investigations into effective prophylactic measures. This meta-analysis aimed to evaluate the efficacy of various prophylactic interventions in reducing the incidence of wound infections following EMR. Adhering to PRISMA guidelines, we conducted a comprehensive search across multiple databases for randomized controlled trials (RCTs) and cohort studies from 2015 to 2022. We included studies that compared the efficacy of antibiotic prophylaxis and antiseptic measures, with clear data on post-procedure infection rates. Eight studies met our inclusion criteria, and data were extracted for meta-analysis. The risk of bias was assessed using the Cochrane Collaboration tool and the Newcastle-Ottawa Scale. The meta-analysis included 3765 patients from eight RCTs. Prophylactic antibiotics (cefixime and cefuroxime) showed moderate to high efficacy, with infection rates as low as 0% and 0.76%. Prophylactic endoscopic closure and clipping showed the highest efficacy, with zero reported infections. The standardized surgical site infection prevention bundle had lower effectiveness, with an infection incidence of 3.83%. The risk of bias assessment indicated potential performance bias due to lack of blinding, but overall evidence quality was upheld by proper random sequence generation and diligent outcome data monitoring. The effectiveness of specific prophylactic measures, notably prophylactic antibiotics and mechanical closure techniques, has been shown in significantly reducing the risk of wound infections following colorectal EMR.
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Affiliation(s)
- Haili Qi
- Department of Endoscopic Diagnosis and TreatmentXinxiang Central HospitalXinxiangChina
| | - Zhimin Wang
- Department of GastroenterologyXinxiang Central HospitalXinxiangChina
| | - Feifei Shen
- Department of Endoscopic Diagnosis and TreatmentXinxiang Central HospitalXinxiangChina
| | - Wei Yu
- Department of Endoscopic Diagnosis and TreatmentXinxiang Central HospitalXinxiangChina
| | - Shasha Duan
- Department of Endoscopic Diagnosis and TreatmentXinxiang Central HospitalXinxiangChina
| | - Xiaohuan Li
- Department of Endoscopic Diagnosis and TreatmentXinxiang Central HospitalXinxiangChina
| | - Xiao Huang
- Zhumadian Central HospitalZhumadianChina
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Shi K, Yang Z, Leng K. Treatment for T1 colorectal cancers substratified by site and size: "horses for courses". Front Med (Lausanne) 2023; 10:1230844. [PMID: 37901402 PMCID: PMC10602675 DOI: 10.3389/fmed.2023.1230844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/21/2023] [Indexed: 10/31/2023] Open
Abstract
Background Owing to advances in diagnostic technology, the diagnosis of T1 colorectal cancers (CRCs) continues to increase. However, the optimal management of T1 CRCs in the Western Hemisphere remains unclear due to limited population-based data directly comparing the efficacy of endoscopic therapy (ET) and surgical resection (SR). The purpose of this study was to report outcome data from a large Western cohort of patients who underwent ET or SR for early CRCs. Methods The SEER-18 database was used to identify patients with T1 CRCs diagnosed from 2004 to 2018 treated with ET or SR. Multivariable logistic regression models were employed to identify variables related to lymph node metastasis (LNM). Rates of ET and 1-year relative survival were calculated for each year. Effect of ET or SR on overall survival and cancer-specific survival was compared using Kaplan-Meier method stratified by tumor size and site. Results A total of 28,430 T1 CRCs patients were identified from 2004 to 2018 in US, with 22.7% undergoing ET and 77.3% undergoing SR. The incidence of T1 CRCs was 6.15 per 100,000 person-years, with male patients having a higher incidence. Left-sided colon was the most frequent location of tumors. The utilization of ET increased significantly from 2004 to 2018, with no significant change in 1-year relative survival rate. Predictors of LNM were age at diagnosis, sex, race, tumor size, histology, grade, and location. The 5-year relative survival rates were 91.4 and 95.4% for ET and SR, respectively. Subgroup analysis showed that OS and CSS were similar between ET and SR in T1N0M0 left-sided colon cancers with tumors 2 cm or less and in rectal cancers with tumors 1 cm or less. Conclusion Our study showed that ET was feasible and safe for patients with left-sided T1N0M0 colon cancers and tumors of 2 cm or less, as well as T1N0M0 rectal cancers and tumors of 1 cm or less. Therefore, the over- and under-use of ET should be avoided by carefully selecting patients based on tumor size and site.
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Affiliation(s)
- Kexin Shi
- The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Zhen Yang
- Department of Hepatopancreatobiliary Surgery, Qingdao Municipal Hospital, Qingdao University, Qingdao, China
- Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, China
| | - Kaiming Leng
- Department of Hepatopancreatobiliary Surgery, Qingdao Municipal Hospital, Qingdao University, Qingdao, China
- Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, China
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5
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Kawaguti FS, Kimura CMS, Moura RN, Safatle-Ribeiro AV, Nahas CSR, Marques CFS, de Rezende DT, Segatelli V, Cotti GCDC, Ribeiro Junior U, Maluf-Filho F, Nahas SC. Impact of a Routine Colorectal Endoscopic Submucosal Dissection in the Surgical Management of Nonmalignant Colorectal Lesions Treated in a Referral Cancer Center. Dis Colon Rectum 2023; 66:e834-e840. [PMID: 36574289 DOI: 10.1097/dcr.0000000000002554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent data show an increasing number of abdominal surgeries being performed for the treatment of nonmalignant colorectal polyps in the West but in settings in which colorectal endoscopic submucosal dissection is not routinely performed. This study evaluated the number of nonmalignant colorectal lesions referred to surgical treatment in a tertiary cancer center that incorporated magnification chromoendoscopy and endoscopic submucosal dissection as part of the standard management of complex colorectal polyps. OBJECTIVE The study aimed to estimate the number of patients with nonmalignant colorectal lesions referred to surgical resection at our institution after the standardization of routine endoscopic submucosal dissection and to describe outcomes for patients undergoing colorectal endoscopic submucosal dissection. DESIGN Single-center retrospective study from a prospectively collected database of endoscopic submucosal dissections and colorectal surgeries performed between January 2016 and December 2019. SETTING Reference cancer center. PATIENTS Consecutive adult patients with complex nonmalignant colorectal polyps were included. INTERVENTIONS Patients with nonmalignant colorectal polyps were treated by endoscopic submucosal dissection or surgery (elective colectomy, rectosigmoidectomy, low anterior resection, or proctocolectomy). MAIN OUTCOMES MEASURES The primary outcome measure was the percentage of patients referred to colorectal surgery for nonmalignant lesions. RESULTS In the study period, 1.1% of 825 colorectal surgeries were performed for nonmalignant lesions, and 97 complex polyps were endoscopically removed by endoscopic submucosal dissection. The en bloc, R0, and curative resection rates of endoscopic submucosal dissection were 91.7%, 83.5%, and 81.4%, respectively. The mean tumor size was 59 (SD 37.8) mm. Perforations during endoscopic submucosal dissection occurred in 3 cases, all treated with clipping. One patient presented with a delayed perforation 2 days after the endoscopic resection and underwent surgery. The mean follow-up period was 3 years, with no tumor recurrence in this cohort. LIMITATIONS Single-center retrospective study. CONCLUSIONS A workflow that includes assessment of the lesions with magnification chromoendoscopy and resection through endoscopic submucosal dissection can lead to a very low rate of abdominal surgery for nonmalignant colorectal lesions. See Video Abstract at http://links.lww.com/DCR/C123 . IMPACTO DE LA DISECCIN SUBMUCOSA ENDOSCPICA COLORRECTAL DE RUTINA EN EL MANEJO QUIRRGICO DE LESIONES COLORRECTALES NO MALIGNAS TRATADAS EN UN CENTRO ONCOLGICO DE REFERENCIA ANTECEDENTES:Datos recientes muestran un número cada vez mayor de cirugías abdominales realizadas para el tratamiento de pólipos colorrectales no malignos en Occidente, pero no en los entornos donde la disección submucosa endoscópica colorrectal se realiza de forma rutinaria. El estudio evaluó el número de lesiones colorrectales no malignas referidas a tratamiento quirúrgico en un centro oncológico terciario, que incorporó cromoendoscopia de aumento y disección submucosa endoscópica como parte del manejo estándar de pólipos colorrectales complejos.OBJETIVO:Estimar el número de pacientes con lesiones colorrectales no malignas referidos para resección quirúrgica en nuestra institución, después de la estandarización de la disección submucosa endoscópica de rutina y describir los resultados para los pacientes sometidos a disección submucosa endoscópica colorrectal.DISEÑO:Estudio retrospectivo de un solo centro, a partir de una base de datos recolectada prospectivamente de disecciones submucosas endoscópicas y cirugías colorrectales realizadas entre enero de 2016 y diciembre de 2019.AJUSTE:Centro oncológico de referencia.PACIENTES:Pacientes adultos consecutivos con pólipos colorrectales no malignos complejos.INTERVENCIONES:Pacientes con pólipos colorrectales no malignos tratados mediante disección submucosa endoscópica o cirugía (colectomía electiva, rectosigmoidectomía, resección anterior baja o proctocolectomía).PRINCIPALES MEDIDAS DE RESULTADO:La medida de resultado primario fue el porcentaje de pacientes remitidos a cirugía colorrectal por lesiones no malignas.RESULTADOS:En el período, 1,1% de 825 cirugías colorrectales fueron realizadas por lesiones no malignas y 97 pólipos complejos fueron extirpados por. disección submucosa endoscópica. Las tasas de resección en bloque, R0 y curativa de disección submucosa endoscópica fueron 91,7%, 83,5% y 81,4%, respectivamente. El tamaño tumoral medio fue de 59 (DE 37,8) mm. Se produjeron perforaciones durante la disección submucosa endoscópica en 3 casos, todos tratados con clipaje. Un paciente presentó una perforación diferida 2 días después de la resección endoscópica y fue intervenido quirúrgicamente. El seguimiento medio fue de 3 años, sin recurrencia tumoral en esta cohorte.LIMITACIONES:Estudio retrospectivo de un solo centro.CONCLUSIONES:Un flujo de trabajo que incluye la evaluación de las lesiones con cromoendoscopia de aumento y resección a través de disección submucosa endoscópica, puede conducir a una tasa muy baja de cirugía abdominal para lesiones colorrectales no malignas. Consulte Video Resumen en http://links.lww.com/DCR/C123 . (Traducción-Dr. Fidel Ruiz Healy ).
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Affiliation(s)
- Fábio S Kawaguti
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | - Cintia Mayumi Sakurai Kimura
- Division of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | - Renata Nobre Moura
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | | | - Caio Sergio Rizkallah Nahas
- Division of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | | | - Daniel Tavares de Rezende
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | - Vanderlei Segatelli
- Division of Pathology, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | | | - Ulysses Ribeiro Junior
- Division of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | - Fauze Maluf-Filho
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
| | - Sergio Carlos Nahas
- Division of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Brazil
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Zhong Y, Jian GL, Li QX, Xiao YY, Ye JY, Liu QX, Zhong MY, Ni D, Pei XQ, Huang WJ. Abdominal Ultrasonography After Transrectal Filling With Contrast Agents in Colorectal Cancer With Severely Stenotic Lesions. ULTRASOUND IN MEDICINE & BIOLOGY 2023:S0301-5629(23)00206-5. [PMID: 37423829 DOI: 10.1016/j.ultrasmedbio.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 05/26/2023] [Accepted: 06/14/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVE Abdominal ultrasonography after transrectal filling with contrast agent (AU-TFCA) was retrospectively evaluated with respect to determination of T stage and lesion length in patients with colorectal cancer (CRC) who had previously failed colonoscopy because of severe intestinal stenosis. METHODS The population comprised 83 patients with CRC with intestinal stenosis and previously failed colonoscopy who underwent AU-TFCA, and in addition contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI), 2 wk before surgery. The diagnostic performance of AU-TFCA and CECT/MRI was evaluated relative to the post-operative pathological results (PPRs) by paired sample t-test, receiver operator characteristic (ROC) curve, Pearson's χ2-test and κ and intraclass correlation coefficients. RESULTS The T staging identified via AU-TFCA, but not CECT/MRI, was relatively consistent with that of the PPRs (linearly weighted κ coefficient: 0.558, p < 0.001, and linearly weighted κ coefficient: 0.237, p < 0.001, respectively). The overall diagnostic accuracy of T staging based on AU-TFCA (83.1%) was significantly higher than that based on CECT/MRI (50.6%). Regarding lesion length, the results of AU-TFCA and PPRs were comparable (t = 1.852, p = 0.068), but those of CECT/MRI and PPRs were significantly different (t = 8.450, p < 0.001). CONCLUSION AU-TFCA is effective in evaluation of lesion length and T stage in patients with severely stenotic CRC lesions who previously failed colonoscopy. The diagnostic accuracy of AU-TFCA is significantly better compared with that of CECT/MRI.
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Affiliation(s)
- Yuan Zhong
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China
| | - Guo-Liang Jian
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China
| | - Qin-Xiang Li
- Department of Medical Radiology, First People's Hospital of Foshan, Foshan, China
| | - Yan-Yan Xiao
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China
| | - Jie-Yi Ye
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China
| | - Qin-Xue Liu
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China
| | - Min-Ying Zhong
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China
| | - Dong Ni
- Shenzhen University, Faculty of Medicine, School of Biomedical Engineering, Nanshan District, Shenzhen, China
| | - Xiao-Qing Pei
- Department of Medical Ultrasound, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Wei-Jun Huang
- Department of Medical Ultrasound, First People's Hospital of Foshan, Foshan, China.
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Attard TM, Cohen S, Durno C. Polyps and Polyposis Syndromes in Children: Novel Endoscopic Considerations. Gastrointest Endosc Clin N Am 2023; 33:463-486. [PMID: 36948756 DOI: 10.1016/j.giec.2022.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Polypectomy is the most common therapeutic endoscopic intervention in children. Management of sporadic juvenile polyps is limited to polypectomy to resolve symptoms, whereas polyposis syndromes pose a multidisciplinary challenge with broader ramifications. In preparation for polypectomy, there are key patient, polyp, endoscopy unit, and provider characteristics that factor into the likelihood of success. Younger age and multiple medical comorbidities increase the risk of adverse outcomes, classified as intraoperative, immediate postoperative, and delayed postoperative complications. Novel techniques, including cold snare polypectomy, can significantly decrease adverse events but a more structured training process for polypectomy in pediatric gastroenterology is needed.
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Affiliation(s)
- Thomas M Attard
- Division of Gastroenterology, Hepatology and Nutrition, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA; The University of Missouri in Kansas City School of Medicine, Kansas City, MO, USA.
| | - Shlomi Cohen
- Pediatric Gastroenterology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Carol Durno
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; The Zane Cohen Centre for Digestive Diseases, 60 Murray Street, Toronto, Ontario M5T 3L9, Canada; Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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8
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Parker J, Gupta S, Shenbagaraj L, Harborne P, Ramaraj R, Karandikar S, Mottershead M, Barbour J, Mohammed N, Lockett M, Lyons A, Vega R, Torkington J, Dolwani S. Outcomes of complex colorectal polyps managed by multi-disciplinary team strategies-a multi-centre observational study. Int J Colorectal Dis 2023; 38:28. [PMID: 36735059 PMCID: PMC9898359 DOI: 10.1007/s00384-022-04299-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Team management strategies for complex colorectal polyps are recommended by professional guidelines. Multi-disciplinary meetings are used across the UK with limited information regarding their impact. The aim of this multi-centre observational study was to assess procedures and outcomes of patients managed using these approaches. METHOD This was a retrospective, observational study of patients managed by six UK sites. Information was collected regarding procedures and outcomes including length of stay, adverse events, readmissions and cancers. RESULTS Two thousand one hundred ninety-two complex polyps in 2109 patients were analysed with increasing referrals annually. Most presented symptomatically and the mean polyp size was 32.1 mm. Primary interventions included endoscopic therapy (75.6%), conservative management (8.3%), colonic resection (8.1%), trans-anal surgery (6.8%) or combined procedures (1.1%). The number of primary colonic resections decreased over the study period without a reciprocal increase in secondary procedures or recurrence. Secondary procedures were required in 7.8%. The median length of stay for endoscopic procedures was 0 days with 77.5% completed as day cases. Median length of stay was 5 days for colonic resections. Overall adverse event and 30-day readmission rates were 9.0% and 3.3% respectively. Malignancy was identified in 8.8%. Benign polyp recurrence occurred in 13.1% with a median follow up of 30.4 months. Screening detected lesions were more likely to undergo bowel resection. Colonic resection was associated with longer stays, higher adverse events and more cancers on final histology. CONCLUSION Multi-disciplinary team management of complex polyps is safe and effective. Standardisation of organisation and quality monitoring is needed to continue positive effects on outcomes and services.
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Affiliation(s)
- J. Parker
- School of Medicine and Cardiff and Vale University Health Board, Cardiff University, Cardiff, UK
| | - S. Gupta
- Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | | | - P. Harborne
- Cardiff and Vale University Health Board, Cardiff, UK
| | - R. Ramaraj
- Cardiff and Vale University Health Board, Cardiff, UK
| | - S. Karandikar
- University Hospitals Birmingham Foundation NHS Trust, Birmingham, UK
| | - M. Mottershead
- University Hospitals Birmingham Foundation NHS Trust, Birmingham, UK
| | - J. Barbour
- Gateshead Health NHS Foundation Trust, Gateshead, UK
| | - N. Mohammed
- Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, UK
| | | | - A. Lyons
- North Bristol NHS Trust, Bristol, UK
| | - R. Vega
- University College London Hospitals NHS Foundation Trust, London, UK
| | - J. Torkington
- Cardiff and Vale University Health Board, Cardiff, UK
| | - S. Dolwani
- School of Medicine and Cardiff and Vale University Health Board, Cardiff University, Cardiff, UK
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9
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Kandel P, Hussain M, Yadav D, Dhungana SK, Brahmbhatt B, Raimondo M, Lukens FJ, Bachuwa G, Wallace MB. Post-EMR for colorectal polyps, thermal ablation of defects reduces adenoma recurrence: A meta-analysis. Endosc Int Open 2022; 10:E1399-E1405. [PMID: 36262518 PMCID: PMC9576327 DOI: 10.1055/a-1922-7646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 08/10/2022] [Indexed: 10/25/2022] Open
Abstract
Background and study aims Adenoma recurrence is one of the key limitations of endoscopic mucosal resection (EMR), which occurs in 15 % to 30 % of cases during first surveillance colonoscopy. The main hypothesis behind adenoma recurrence is leftover micro-adenomas at the margins of post-EMR defects. In this systematic review and meta-analysis, we evaluated the efficacy of snare tip soft coagulation (STSC) at the margins of mucosal defects to reduce adenoma recurrence and bleeding complications. Methods Electronic databases such as PubMed and the Cochrane library were used for systematic literature search. Studies with polyps only resected by piecemeal EMR and active treatment: with STSC, comparator: non-STSC were included. A random effects model was used to calculate the summary of risk ratio and 95 % confidence intervals. The main outcome of the study was to compare the effect of STSC versus non-STSC with respect to adenoma recurrence at first surveillance colonoscopy after thermal ablation of post-EMR defects. Results Five studies were included in the systematic review and meta-analysis. The total number patients who completed first surveillance colonoscopy (SC1) in the STSC group was 534 and in the non-STSC group was 514. The pooled adenoma recurrence rate was 6 % (37 of 534 cases) in the STSC arm and 22 % (115 of 514 cases) in the non-STSC arm, (odds ratio [OR] 0.26, 95 % confidence interval [CI], 0.16-0.41, P = 0.001). The pooled delayed post-EMR bleeding rate 19 % (67 of 343) in the STSC arm and 22 % (78 of 341) in the non-STSC arm (OR 0.82, 95 %CI, 0.57-1.18). Conclusions Thermal ablation of post-EMR defects significantly reduces adenoma recurrence at first surveillance colonoscopy.
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Affiliation(s)
- Pujan Kandel
- Michigan State University/Hurley Medical Center, Flint, Michigan, United States
| | - Murtaza Hussain
- Michigan State University/Hurley Medical Center, Flint, Michigan, United States
| | - Deepesh Yadav
- Michigan State University/Hurley Medical Center, Flint, Michigan, United States
| | - Santosh K. Dhungana
- Michigan State University/Hurley Medical Center, Flint, Michigan, United States
| | | | - Massimo Raimondo
- Mayo Clinic's Campus in Florida, Jacksonville, Florida, United States
| | - Frank J. Lukens
- Mayo Clinic's Campus in Florida, Jacksonville, Florida, United States
| | - Ghassan Bachuwa
- Michigan State University/Hurley Medical Center, Flint, Michigan, United States
| | - Michael B. Wallace
- Mayo Clinic's Campus in Florida, Jacksonville, Florida, United States,Division of Gastroenterology and Hepatology, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
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10
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Rowsell C. Refining the Risk of Lymph Node Metastasis in T1 Colorectal Adenocarcinoma. Gastroenterology 2022; 163:46-47. [PMID: 35513008 DOI: 10.1053/j.gastro.2022.04.049] [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: 04/27/2022] [Accepted: 04/29/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Corwyn Rowsell
- Unity Health Toronto, Laboratory Medicine, Toronto, Ontario, Canada.
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11
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Alam A, Ma C, Jiang SF, Jensen CD, Webb KH, Boparai ES, Jue TL, Munroe CA, Gupta S, Fox J, Hamerski CM, Velayos FS, Corley DA, Lee JK. Declining Colectomy Rates for Nonmalignant Colorectal Polyps in a Large, Ethnically Diverse, Community-Based Population. Clin Transl Gastroenterol 2022; 13:e00477. [PMID: 35347095 PMCID: PMC9132519 DOI: 10.14309/ctg.0000000000000477] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/09/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Despite studies showing improved safety, efficacy, and cost-effectiveness of endoscopic resection for nonmalignant colorectal polyps, colectomy rates for nonmalignant colorectal polyps have been increasing in the United States and Europe. Given this alarming trend, we aimed to investigate whether colectomy rates for nonmalignant colorectal polyps are increasing or declining in a large, integrated, community-based healthcare system with access to advanced endoscopic resection procedures. METHODS We identified all individuals aged 50-85 years who underwent a colonoscopy between 2008 and 2018 and were diagnosed with a nonmalignant colorectal polyp(s) at the Kaiser Permanente Northern California integrated healthcare system. Among these individuals, we identified those who underwent a colectomy for nonmalignant colorectal polyps within 12 months after the colonoscopy. We calculated annual colectomy rates for nonmalignant colorectal polyps and stratified rates by age, sex, and race and ethnicity. Changes in rates over time were tested by the Cochran-Armitage test for a linear trend. RESULTS Among 229,730 patients who were diagnosed with nonmalignant colorectal polyps between 2008 and 2018, 1,611 patients underwent a colectomy. Colectomy rates for nonmalignant colorectal polyps decreased significantly from 125 per 10,000 patients with nonmalignant polyps in 2008 to 12 per 10,000 patients with nonmalignant polyps in 2018 (P < 0.001 for trend). When stratified by age, sex, and race and ethnicity, colectomy rates for nonmalignant colorectal polyps also significantly declined from 2008 to 2018. DISCUSSION In a large, ethnically diverse, community-based population in the United States, we found that colectomy rates for nonmalignant colorectal polyps declined significantly over the past decade likely because of the establishment of advanced endoscopy centers, improved care coordination, and an organized colorectal cancer screening program.
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Affiliation(s)
- Asim Alam
- Internal Medicine/Preventive Medicine Residency Program, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
| | - Christopher Ma
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sheng-Fang Jiang
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA;
| | - Christopher D. Jensen
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA;
| | - Kenneth H. Webb
- University of California, Berkeley, School of Public Health and Haas School of Business, Berkeley, California, USA;
| | - Eshandeep S. Boparai
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
| | - Terry L. Jue
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA;
| | - Craig A. Munroe
- Division of Gastroenterology, University of California San Francisco, San Francisco, California, USA;
| | - Suraj Gupta
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
| | - Jeffrey Fox
- Department of Gastroenterology, Kaiser Permanente San Rafael Medical Center, San Rafael, California, USA.
| | - Christopher M. Hamerski
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
| | - Fernando S. Velayos
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
| | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA;
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
| | - Jeffrey K. Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA;
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA;
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12
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Ge PS, Aihara H. Advanced Endoscopic Resection Techniques: Endoscopic Submucosal Dissection and Endoscopic Full-Thickness Resection. Dig Dis Sci 2022; 67:1521-1538. [PMID: 35246802 DOI: 10.1007/s10620-022-07392-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 02/08/2023]
Abstract
Endoscopic resection is first-line therapy in the management of superficial neoplasms throughout the gastrointestinal tract, as well as an increasingly viable therapeutic alternative in the resection of selected small deep lesions throughout the upper and lower gastrointestinal tract. The mainstay of therapy has traditionally been endoscopic snare polypectomy and endoscopic mucosal resection. However, recent innovative advancements in therapeutic endoscopy have provided for the ability to resect large superficial lesions and selected subepithelial lesions in en bloc and margin-negative fashion. In this review, we discuss the current state of the art in advanced endoscopic resection techniques including endoscopic submucosal dissection and endoscopic full-thickness resection.
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Affiliation(s)
- Phillip S Ge
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1466, Houston, TX, 77030-4009, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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13
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Kwok K, Tran T, Lew D. Polypectomy for Large Polyps with Endoscopic Mucosal Resection. Gastrointest Endosc Clin N Am 2022; 32:259-276. [PMID: 35361335 DOI: 10.1016/j.giec.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Beginning in 1955, when the saline injection was first described to prevent transmural injury during polyp fulguration, endoscopic mucosal resection (EMR) has grown exponentially, both in scope and in practice. Because EMR is an organ-preserving technique even for large polyps, this allows for comparable outcomes to surgery, but substantially improved cost savings and significantly reduced morbidity and mortality. To achieve this, however, one must master the 4 fundamental components that are critical to the success of EMR- time, team, tools, and technique. This article aims to provide a compendium of state of the art updates within the field of endoluminal resection.
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Affiliation(s)
- Karl Kwok
- Interventional Endoscopy, Division of Gastroenterology, Kaiser Permanente, Los Angeles Medical Center, 1526 North Edgemont Street, 7th Floor, Los Angeles, CA 90027, USA.
| | - Tri Tran
- Department of Medicine, Kaiser Permanente, Los Angeles Medical Center, 4867 W Sunset Boulevard, Los Angeles, CA 90027, USA
| | - Daniel Lew
- Division of Gastroenterology, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
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14
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Keane MG, Mony S, Wood LD, Kumbhari V, Khashab MA. Prophylactic appendiceal retrograde intraluminal stent placement (PARIS). VideoGIE 2021; 6:552-554. [PMID: 34917867 PMCID: PMC8646081 DOI: 10.1016/j.vgie.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Margaret G Keane
- Johns Hopkins Hospital, Department of Gastroenterology and Hepatology, Baltimore, Maryland
| | - Shruti Mony
- Johns Hopkins Hospital, Department of Gastroenterology and Hepatology, Baltimore, Maryland
| | - Laura D Wood
- Sol Goldamn Pancreatic Cancer Research Center, Johns Hopkins University, Baltimore, Maryland
| | - Vivek Kumbhari
- Johns Hopkins Hospital, Department of Gastroenterology and Hepatology, Baltimore, Maryland
| | - Mouen A Khashab
- Johns Hopkins Hospital, Department of Gastroenterology and Hepatology, Baltimore, Maryland
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15
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Ortiz O, Rex DK, Grimm IS, Moyer MT, Hasan MK, Pleskow D, Elmunzer BJ, Khashab MA, Sanaei O, Al-Kawas FH, Gordon SR, Mathew A, Levenick JM, Aslanian HR, Antaki F, von Renteln D, Crockett SD, Rastogi A, Gill JA, Law R, Wallace MB, Elias PA, MacKenzie TA, Pohl H, Pellisé M. Factors associated with complete clip closure after endoscopic mucosal resection of large colorectal polyps. Endoscopy 2021; 53:1150-1159. [PMID: 33291159 DOI: 10.1055/a-1332-6727] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND STUDY AIM : Delayed bleeding is a common adverse event following endoscopic mucosal resection (EMR) of large colorectal polyps. Prophylactic clip closure of the mucosal defect after EMR of nonpedunculated polyps larger than 20 mm reduces the incidence of severe delayed bleeding, especially in proximal polyps. This study aimed to evaluate factors associated with complete prophylactic clip closure of the mucosal defect after EMR of large polyps. METHODS : This is a post hoc analysis of the CLIP study (NCT01936948). All patients randomized to the clip group were included. Main outcome was complete clip closure of the mucosal resection defect. The defect was considered completely closed when no remaining mucosal defect was visible and clips were less than 1 cm apart. Factors associated with complete closure were evaluated in multivariable analysis. RESULTS : In total, 458 patients (age 65, 58 % men) with 494 large polyps were included. Complete clip closure of the resection defect was achieved for 338 polyps (68.4 %); closure was not complete for 156 (31.6 %). Factors associated with complete closure in adjusted analysis were smaller polyp size (odds ratio 1.06 for every millimeter decrease [95 % confidence interval 1.02-1.08]), good access (OR 3.58 [1.94-9.59]), complete submucosal lifting (OR 2.28 [1.36-3.90]), en bloc resection (OR 5.75 [1.48-22.39]), and serrated histology (OR 2.74 [1.35-5.56]). CONCLUSIONS : Complete clip closure was not achieved for almost one in three resected large nonpedunculated polyps. While stable access and en bloc resection facilitate clip closure, most factors associated with clip closure are not modifiable. This highlights the need for alternative closure options and measures to prevent bleeding.
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Affiliation(s)
- Oswaldo Ortiz
- Gastroenterology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ian S Grimm
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Matthew T Moyer
- Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Muhammad K Hasan
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Douglas Pleskow
- Division of Gastroenterology Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Firas H Al-Kawas
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Sibley Memorial Hospital, Washington, DC, USA
| | - Stuart R Gordon
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA.,Department of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Abraham Mathew
- Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - John M Levenick
- Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Harry R Aslanian
- Section of Digestive Diseases, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Fadi Antaki
- Division of Gastroenterology, John D. Dingell Veterans Affairs Medical Center and Wayne State University, Detroit, Michigan, USA
| | - Daniel von Renteln
- Division of Gastroenterology, University of Montreal Medical Center (CHUM) and Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Seth D Crockett
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Amit Rastogi
- Division of Gastroenterology, Hepatology, and Motility, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jeffrey A Gill
- Division of Gastroenterology, James A. Haley VA, University of South Florida, Tampa, Florida, USA
| | - Ryan Law
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael B Wallace
- Department of Gastroenterology, Mayo Clinic, Jacksonville, Florida, USA
| | - Pooja A Elias
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Todd A MacKenzie
- The Dartmouth Institute, Department for Biomedical Data Science, Lebanon, New Hampshire, USA
| | - Heiko Pohl
- Department of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA.,Section of Gastroenterology and Hepatology, VA White River Junction, Vermont, USA
| | - Maria Pellisé
- Department of Gastroenterology, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Hospital Clinic of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Universitat de Barcelona, Barcelona, Spain
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16
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Postoperative Hospital Outcomes of Elective Surgery for Nonmalignant Colorectal Polyps: Does the Burden Justify the Indication? Am J Gastroenterol 2021; 116:1938-1945. [PMID: 34255758 DOI: 10.14309/ajg.0000000000001374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 06/24/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Despite the increasing availability of advanced endoscopic resections and its favorable safety profile, surgery for nonmalignant colorectal polyps has continually increased. We sought to evaluate readmission rates and outcomes of elective surgery for nonmalignant colorectal polyps on a national level in the United States. METHODS The Nationwide Readmissions Database (2010-2014 [International Classification of Diseases, Ninth Revision] and 2016-2018 [International Classification of Diseases, 10th Revision]) was used to identify all adult subjects (age ≥18 years) who underwent elective surgical resection of nonmalignant colorectal polyps. Multivariable analyses were performed for predictors of postoperative morbidity and 30-day readmission. RESULTS Elective surgery for nonmalignant colorectal polyps was performed in 108,468 subjects from 2010 to 2014 and in 54,956 subjects from 2016 to 2018, most of whom were laparoscopic. Postoperative morbidity and 30-day readmission rates were 20.5% and 8.5% from 2010 to 2014, and 13.0% and 7.6% from 2016 to 2018, respectively. Index admission mortality rates were 0.3-0.4%; mortality rates were higher in those with postoperative morbidity. Multivariable analyses revealed that male sex, ≥3 comorbidities, insurance status, and open surgery predicted an increased risk of both postoperative morbidity and 30-day readmission. In addition, postoperative morbidity (2010-2014 [odds ratio 1.58; 95% confidence interval 1.44-1.74] and 2016-2018 [odds ratio 1.55; 95% confidence interval 1.37-1.75]) predicted early readmission. DISCUSSION In this investigation of national practices, elective surgery for nonmalignant colorectal polyps remains common. There is considerable risk of adverse postoperative outcomes, which highlights the importance of increasing awareness of the range of endoscopic resections and referring subjects to expert endoscopy centers.
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17
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Kumar R, Harilal S, Carradori S, Mathew B. A Comprehensive Overview of Colon Cancer- A Grim Reaper of the 21st Century. Curr Med Chem 2021; 28:2657-2696. [PMID: 33106132 DOI: 10.2174/0929867327666201026143757] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 09/18/2020] [Accepted: 09/18/2020] [Indexed: 12/09/2022]
Abstract
A few decades ago, the incidence of colorectal cancer (CRC) was low and is now the fourth in the list of deadly cancers producing nearly a million deaths annually. A population that is aging along with risk factors such as smoking, obesity, sedentary lifestyle with little or no physical activity, and non-healthy food habits of developed countries can increase the risk of colorectal cancer. The balance in gut microbiota and the metabolites produced during bacterial fermentation within the host plays a significant role in regulating intestinal diseases as well as colorectal cancer development. Recent progress in the understanding of illness resulted in multiple treatment options such as surgery, radiation, and chemotherapy, including targeted therapy and multitherapies. The treatment plan for CRC depends on the location, stage and grade of cancer as well as genomic biomarker tests. Despite all the advancements made in the genetic and molecular aspects of the disease, the knowledge seems inadequate as the drug action as well as the wide variation in drug response did not appear strongly correlated with the individual molecular and genetic characteristics, which suggests the requirement of comprehensive molecular understanding of this complex heterogeneous disease. Furthermore, multitherapies or a broad spectrum approach, which is an amalgamation of the various promising as well as effective therapeutic strategies that can tackle heterogeneity and act on several targets of the disease, need to be validated in clinical studies. The latest treatment options have significantly increased the survival of up to three years in the case of advanced disease. The fact that colorectal cancer is developed from a polypoid precursor, as well as the symptoms of the disease that occur at an advanced stage, underlines how screening programs can help early detection and decrease mortality as well as morbidity from CRC.
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Affiliation(s)
- Rajesh Kumar
- Department of Pharmacy, Kerala University of Health Sciences, Thrissur, Kerala, India
| | - Seetha Harilal
- Department of Pharmacy, Kerala University of Health Sciences, Thrissur, Kerala, India
| | - Simone Carradori
- Department of Pharmacy, "G. d'Annunzio" University of Chieti-Pescara, via dei Vestini 31, 66100 Chieti, Italy
| | - Bijo Mathew
- Department of Pharmaceutical Chemistry, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, AIMS Health Sciences Campus, Kochi-682 041, India
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18
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Kidambi TD, Lee JK. Validated training tools are needed for assessing competency in colorectal endoscopic mucosal resection. Gastrointest Endosc 2021; 93:776-777. [PMID: 33583531 DOI: 10.1016/j.gie.2020.10.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 10/11/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Trilokesh D Kidambi
- Division of Gastroenterology, City of Hope Medical Center, Duarte, California, USA
| | - Jeffrey K Lee
- Kaiser Permanente Division of Research, Oakland, California, USA; Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
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19
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Li A, Yang JZ, Yang XX, Feng BC, Zhang MM, Qu JY, Zhou RC, Wang P, Li LX, Zuo XL, Li YQ. Endocuff-assisted colonoscopy versus cap-assisted colonoscopy for adenoma detection rate: A meta-analysis of randomized controlled trials. J Gastroenterol Hepatol 2020; 35:2066-2073. [PMID: 32562282 DOI: 10.1111/jgh.15155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/08/2020] [Accepted: 06/11/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS Add-on devices have been widely used in clinical practice. The aim of this meta-analysis was to compare the adenoma detection rate between Endocuff-assisted colonoscopy (EAC) and cap-assisted colonoscopy (CAC). METHODS PubMed, EMBASE, SCOPUS, and Cochrane databases were searched. Outcomes included adenoma detection rate, cecal intubation rate, cecal intubation time, and withdrawal time. Dichotomous data were pooled to obtain the odds ratio or risk ratio. Continuous data were pooled using the mean difference. RESULTS Of the 240 articles reviewed, six randomized controlled trials were included, with a total of 1994 patients. In the meta-analysis, no statistical difference in adenoma detection rate was detected between EAC and CAC (47.0% vs 45.1%; P = 0.33). EAC significantly improved detection rate of diminutive adenomas/polyps compared with CAC (P = 0.01). Cecal intubation was achieved in 96.5% in EAC group and 97.9% in CAC group (P = 0.04). Besides, no statistical difference was found in cecal intubation time (P = 0.86), withdrawal time (P = 0.88), small adenomas/polyps (P = 0.60), or large adenomas/polyps (P = 0.95). CONCLUSION EAC and CAC have their respective merits. EAC significantly improve the detection of diminutive adenomas/polyps. CAC was better in cecal intubation rate.
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Affiliation(s)
- Ai Li
- Department of Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI tumor, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China
| | - Jing-Ze Yang
- Department of Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI tumor, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China
| | - Xiao-Xiao Yang
- Department of Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI tumor, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China
| | - Bing-Cheng Feng
- Department of Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI tumor, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China
| | - Ming-Ming Zhang
- Department of Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI tumor, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China
| | - Jun-Yan Qu
- Department of Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI tumor, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China
| | - Ru-Chen Zhou
- Department of Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI tumor, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China
| | - Peng Wang
- Department of Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI tumor, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China
| | - Li-Xiang Li
- Department of Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI tumor, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China
| | - Xiu-Li Zuo
- Department of Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI tumor, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China
| | - Yan-Qing Li
- Department of Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Laboratory of Translational Gastroenterology, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China.,Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI tumor, Qilu Hospital, Cheloo College of Medicine, Shandong University, Jinan, China
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20
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Mouchli MA, Reddy S, Walsh C, Mir A, Bierle L, Chitnavis V, Yeaton P, Shakhatreh M. Outcomes of Gastrointestinal Polyps Resected Using Underwater Endoscopic Mucosal Resection (UEMR) Compared to Conventional Endoscopic Mucosal Resection (CEMR). Cureus 2020; 12:e11485. [PMID: 33329981 PMCID: PMC7735526 DOI: 10.7759/cureus.11485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objective Underwater endoscopic mucosal resection (UEMR) is reported to be superior to conventional endoscopic mucosal resection (CMER) for the complete resection of large polyps and may offer increased procedural efficiency. Aims To compare recurrence rates and adverse events between UEMR and CEMR and define risk factors related to recurrence. Also, to assess recurrence rates in piecemeal endoscopic mucosal resection (EMR) based on the number of pieces resected. Methods We identified all patients with large polyps treated using the UEMR technique at Carilion Clinic, Roanoke, VA, USA between January 1, 2014 and December 31, 2017 with follow-up through October of 2018. We matched the UEMR patients with patients treated using the CEMR technique (1:2 matching, respectively). The Kaplan-Meier curve was used to estimate the cumulative risks of polyp recurrence. The Cox proportional hazard analysis was used to assess risk factors for developing polyp recurrence. Results Sixty-eight patients (mean age: 63.4 ± 12.5 years; 52.9% males) with polyps removed using the UEMR technique (Group 1) were matched with 122 patients (mean age: 64.4 ± 10.0 years; 51.6% males) who had polyps removed using CEMR (Group 2). Polyps resected in fewer pieces (≤ 3) had lower recurrence rates compared to the ones resected in >3 pieces. Right colon polyps removed using UEMR had a lower recurrence rate compared to right colon polyps resected using CEMR. Polyp size and a high degree of dysplasia were associated with a high risk of polyp recurrence after resection. Completing advanced endoscopy training was also associated with a lower risk of recurrence. Conclusion UEMR had a lower recurrence rate compared with CEMR for right colon polyps. Factors associated with recurrence included the degree of training, high-grade dysplasia, and polyp size.
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21
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Yu J, Zhang Y, Qian J. Endoscopic submucosal dissection in the treatment of patients with early colorectal carcinoma and precancerous lesions. J Gastrointest Oncol 2020; 11:911-917. [PMID: 33209487 PMCID: PMC7657837 DOI: 10.21037/jgo-20-393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/12/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Our study aims to explore the indications and clinical efficacy of endoscopic submucosal dissection (ESD) on the early colorectal carcinoma and precancerous lesions. METHODS The clinical data of 29 patients with early colorectal carcinoma and precancerous lesions who were treated with ESD at Nantong First People's Hospital between January 2018 and December 2019 were collected. Then the endoscopic morphology, postoperative pathological classification, tumor resection rate, postoperative complications, and follow-up outcomes were analyzed. RESULTS Colorectal carcinoma lesions were distributed in the left colon, accounting for 89.6%. There were 14 cases (48.3%) with protuberant endoscopic tumors, accounting for the highest proportion, while 2 cases (6.9%) of the flat tumors, accounting for the lowest proportion. The average operation time for ESD was 123 minutes, and en-bloc resection was 100% while the curative resection rate was 89.6%. There were 3 cases (10.3%) with delayed hemorrhage after ESD, and 1 case with persistent hemorrhage during the operation was transferred to surgical treatment. No cases with infection or perforation after ESD. For postoperative pathological classification, villous-tubular adenoma with low-grade epithelioma accounted for 31%; tubular adenoma with high-grade epithelioma only accounted for 3.4%. There was no recurrence in the follow-up for 1-20 months. CONCLUSIONS Control of surgical indications strictly, improvement of operation skills, attention to postoperative pathological feedback, and close follow-up are necessary guarantees to improve the clinical effectiveness of ESD.
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Affiliation(s)
- Jing Yu
- Department of Gastroenterology, the Second Affiliated Hospital of Nantong University, Nantong, China
| | - Yan Zhang
- Department of Gastroenterology, the Second Affiliated Hospital of Nantong University, Nantong, China
| | - Junbo Qian
- Department of Gastroenterology, the Second Affiliated Hospital of Nantong University, Nantong, China
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22
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Krutzenbichler I, Dollhopf M, Diepolder H, Eigler A, Fuchs M, Herrmann S, Kleber G, Lewerenz B, Kaiser C, Lilje T, Rath T, Agha A, Vitali F, Schäfer C, Schepp W, Gundling F. Technical success, resection status, and procedural complication rate of colonoscopic full-wall resection: a pooled analysis from 7 hospitals of different care levels. Surg Endosc 2020; 35:3339-3353. [PMID: 32648038 PMCID: PMC8195906 DOI: 10.1007/s00464-020-07772-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/25/2020] [Indexed: 12/17/2022]
Abstract
Introduction Endoscopic full-thickness resection (eFTR) using the full-thickness resection device (FTRD®) is a novel minimally invasive procedure that allows the resection of various lesions in the gastrointestinal tract including the colorectum. Real-world data outside of published studies are limited. The aim of this study was a detailed analysis of the outcomes of colonoscopic eFTR in different hospitals from different care levels in correlation with the number of endoscopists performing eFTR. Material and methods In this case series, the data of all patients who underwent eFTR between November 2014 and June 2019 (performed by a total of 22 endoscopists) in 7 hospitals were analyzed retrospectively regarding rates of technical success, R0 resection, and procedure-related complications. Results Colonoscopic eFTR was performed in 229 patients (64.6% men; average age 69.3 ± 10.3 years) mainly on the basis of the following indication: 69.9% difficult adenomas, 21.0% gastrointestinal adenocarcinomas, and 7.9% subepithelial tumors. The average size of the lesions was 16.3 mm. Technical success rate of eFTR was achieved in 83.8% (binominal confidence interval 78.4–88.4%). Overall, histologically complete resection (R0) was achieved in 77.2% (CI 69.8–83.6%) while histologically proven full-wall excidate was confirmed in 90.0% (CI 85.1–93.7%). Of the resectates obtained (n = 210), 190 were resected en bloc (90.5%). We did not observe a clear improvement of technical success and R0 resection rate over time by the performing endoscopists. Altogether, procedure-related complications were observed in 17.5% (mostly moderate) including 2 cases of acute gangrenous appendicitis requiring operation. Discussion In this pooled analysis, eFTR represents a feasible, effective, and safe minimally invasive endoscopic technique. Electronic supplementary material The online version of this article (10.1007/s00464-020-07772-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Irmengard Krutzenbichler
- Department of Gastroenterology, Hepatology and Gastrointestinal Oncology, Bogenhausen Academic Teaching Hospital, Technical University of Munich, Munich, Germany
| | - Markus Dollhopf
- Division of Gastroenterology and Hepatology, Klinikum Neuperlach, Munich, Germany
| | | | - Andreas Eigler
- Klinik für Innere Medizin I, Klinikum Dritter Orden München-Nymphenburg, Munich, Germany
| | - Martin Fuchs
- Department of Gastroenterology, Hepatology and Gastrointestinal Oncology, Bogenhausen Academic Teaching Hospital, Technical University of Munich, Munich, Germany
| | - Simon Herrmann
- Division of Gastroenterology and Hepatology, Klinikum Neuperlach, Munich, Germany
| | | | - Björn Lewerenz
- Department of Gastroenterology, Hepatology and Gastrointestinal Oncology, Bogenhausen Academic Teaching Hospital, Technical University of Munich, Munich, Germany
| | - Christoph Kaiser
- Klinik für Innere Medizin I, Klinikum Dritter Orden München-Nymphenburg, Munich, Germany
| | - Tilman Lilje
- Kliniken Ostallgäu-Kaufbeuren, Klinikum Kaufbeuren, Germany
| | - Timo Rath
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, 91054, Erlangen, Germany
| | - Ayman Agha
- Klinik für Allgemein-, Viszeral-, Endokrine Und Minimal-Invasive Chirurgie, Klinikum Bogenhausen, Technical University of Munich, Munich, Germany
| | - Francesco Vitali
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, 91054, Erlangen, Germany
| | - Claus Schäfer
- Medical Clinic II, Klinikum Neumarkt, Neumarkt, Germany
| | - Wolfgang Schepp
- Department of Gastroenterology, Hepatology and Gastrointestinal Oncology, Bogenhausen Academic Teaching Hospital, Technical University of Munich, Munich, Germany
| | - Felix Gundling
- Department of Gastroenterology, Hepatology and Gastrointestinal Oncology, Bogenhausen Academic Teaching Hospital, Technical University of Munich, Munich, Germany. .,Department for Gastroenterology, Diabetics and Endocrinology, Kemperhof Hospital, Gemeinschaftsklinikum Mittelrhein, Koblenz, Germany.
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Villa E, Stier M, Donboli K, Chapman CG, Siddiqui UD, Waxman I. Dissection-enabled scaffold-assisted resection (DeSCAR): a novel technique for resection of residual or non-lifting gastrointestinal neoplasia of the colon, expanded experience and follow-up. Endosc Int Open 2020; 8:E724-E732. [PMID: 32490156 PMCID: PMC7247895 DOI: 10.1055/a-1132-5323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/20/2020] [Indexed: 11/02/2022] Open
Abstract
Background and study aims Colonic lesions may not be amenable to conventional endoscopic mucosal resection (EMR) due to previous manipulation, submucosal invasion, or lesion flatness. In 2018, we described Dissection-enabled Scaffold Assisted Resection (DeSCAR) to be safe for the endoscopic resection of non-lifting or residual colonic lesions 1 In this study, we expand our original cohort to describe our expanded experience with patients undergoing DeSCAR and assess the efficacy, safety, and feasibility of DeSCAR for endoscopic resection of non-lifting or residual colonic lesions. Patients and methods We retrospectively reviewed 57 patients from 2015-2019 who underwent DeSCAR for colonic lesions with incomplete lifting and/or previous manipulation. Cases were reviewed for location, prior manipulation, rates of successful resection, adverse events, and endoscopic follow up to assess for residual lesions. Results Fifty-seven lesions underwent DeSCAR. Of the patients, 51 % were female, and average patient age was 69 years. Lesions were located in the cecum (n = 16), right colon (n = 27), left colon (n = 10), and rectum (n = 4). Average lesion size was 27.7 mm. Previous manipulation occurred in 54 cases (72 % biopsy, 44 % resection attempt, 18 % intralesional tattoo). The technical success rate for resection of non-lifting lesions was 98 %. There were two delayed bleeding episodes (one required endoscopic intervention) and one small perforation (managed by endoscopic hemoclip closure). Endoscopic follow up was available in 31 patients (54 %) with no residual adenoma in 28 patients (90 % of those surveilled). Conclusions Our expanded experience with DeSCAR demonstrates high safety, feasibility, and effectiveness for the endoscopic management of non-lifting or residual colonic lesions.
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Affiliation(s)
- Edward Villa
- University of Chicago Medical Center, Center for Endoscopic Research and Therapeutics (CERT), Chicago, Illinois, United States
| | - Matthew Stier
- University of Chicago Medical Center, Center for Endoscopic Research and Therapeutics (CERT), Chicago, Illinois, United States
| | - Kianoush Donboli
- University of Chicago Medical Center, Center for Endoscopic Research and Therapeutics (CERT), Chicago, Illinois, United States
| | - Christopher Grant Chapman
- University of Chicago Medical Center, Center for Endoscopic Research and Therapeutics (CERT), Chicago, Illinois, United States
| | - Uzma D. Siddiqui
- University of Chicago Medical Center, Center for Endoscopic Research and Therapeutics (CERT), Chicago, Illinois, United States
| | - Irving Waxman
- University of Chicago Medical Center, Center for Endoscopic Research and Therapeutics (CERT), Chicago, Illinois, United States
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Guillaumot MA, Barret M, Jacques J, Legros R, Pioche M, Rivory J, Rahmi G, Lepilliez V, Chabrun E, Leblanc S, Chaussade S. Endoscopic full-thickness resection of early colorectal neoplasms using an endoscopic submucosal dissection knife: a retrospective multicenter study. Endosc Int Open 2020; 8:E611-E616. [PMID: 32355878 PMCID: PMC7164998 DOI: 10.1055/a-1127-3092] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 01/23/2020] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Endoscopic full-thickness resection allows resection of early gastrointestinal neoplasms not amenable to conventional endoscopic resection techniques, due to their location, presence of submucosal fibrosis, or suspected deep mural invasion. It is typically achieved using a dedicated over-the-scope device (full-thickness resection device or FTRD). The aim of our study was to evaluate the feasibility, safety, and clinical outcomes of endoscopic full-thickness resection using an endoscopic submucosal dissection (ESD) knife. Patients and methods Consecutive patients who underwent full-thickness endoscopic resection at six tertiary care centers from August 2010 to June 2017 were retrospectively included. We conducted a comparative analysis of patient characteristics, technical success, adverse events, and time to discharge between patients treated by a full-thickness resection using an ESD knife. Results Twenty-one procedures were performed using an ESD knife. En-bloc resection and R0 resection rates were 95.2 % and 65 %, respectively. Clinical symptoms of perforation occurred in 66.7 %. There was no need for surgery or additional endoscopic procedures. Conclusion Endoscopic full-thickness resection of early colorectal neoplasms using an ESD knife might be feasible and safe. It allows complete resection of lesions with no limitation in size. The technique may be preferable to an other-the-scope resection device in lesions larger than 20 mm, and to surgery in selected cases of low-risk T1 colorectal carcinomas, non-lifting adenomas, submucosal tumors, or technically challenging lesion locations.
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Affiliation(s)
- Marie-Anne Guillaumot
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hopitaux de Paris, and University of Paris, France
| | - Maximilien Barret
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hopitaux de Paris, and University of Paris, France
| | - Jérémie Jacques
- Department of Gastroenterology, Limoges University Hospital, Limoges, France
| | - Romain Legros
- Department of Gastroenterology, Limoges University Hospital, Limoges, France
| | - Mathieu Pioche
- Department of Gastroenterology, Edouard Herriot Hospital, Lyon, France
| | - Jérome Rivory
- Department of Gastroenterology, Edouard Herriot Hospital, Lyon, France
| | - Gabriel Rahmi
- Department of Gastroenterology and Digestive Endoscopy, Georges Pompidou European Hospital, Assistance Publique – Hopitaux de Paris, and University of Paris, France
| | - Vincent Lepilliez
- Department of Gastroenterology, Ramsay Générale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - Edouard Chabrun
- Department of Endoscopy and Gastroenterology, Bordeaux University Hospital, Bordeaux, France
| | - Sarah Leblanc
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hopitaux de Paris, and University of Paris, France
| | - Stanislas Chaussade
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hopitaux de Paris, and University of Paris, France
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25
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A large multicenter cohort on the use of full-thickness resection device for difficult colonic lesions. Surg Endosc 2020; 35:1296-1306. [PMID: 32180001 DOI: 10.1007/s00464-020-07504-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 03/03/2020] [Indexed: 02/07/2023]
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Patel M, Haque M, Kohli D, Mutha P, Shah SA, Fernandez L, Zfass A, Shah T. Endoscopic resection reduces morbidity when compared to surgery in veterans with large and complex colorectal polyps. Surg Endosc 2020; 35:1164-1170. [PMID: 32166551 DOI: 10.1007/s00464-020-07482-y] [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: 10/30/2019] [Accepted: 02/26/2020] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Data supporting endoscopic resection (ER) over surgical resection (SR) for large and complex polyps come from high-volume centers. The aim of this study was to determine whether these favorable outcomes can be replicated among endoscopists at tertiary Veterans Affairs Medical Centers (VAMCs) who perform 25 to 30 ER cases a year. METHODS Patients with adenomatous polyps or intra-mucosal cancers ≥ 2 cm in size who underwent ER or SR were identified from prospectively maintained databases at the 2 tertiary VAMCs in Veterans Integrated Service Network 6 (VISN6). The primary outcome was the rate of serious complications in the ER and SR groups. RESULTS 310 ER and 81 SR patients met the inclusion criteria. ER was successful in 97% of all polyps, and 93% of polyps ≥ 4 cm. The rate of serious complications was significantly lower with ER compared to SR (0.6% vs. 22%, p = 0.00001). These findings persisted even after limiting the analysis to polyps ≥ 4 cm and after propensity score matching. If all ER patients had instead undergone laparoscopic surgery, the estimated risk of a serious complication was still higher than ER for all patients (8% vs. 0.6%, p < 0.0001) but not significantly higher for polyps ≥ 4 cm (8% vs 2%, p = 0.17). CONCLUSIONS This study documents high success rates for ER in veterans with colorectal polyps ≥ 2 cm and ≥ 4 cm. When compared to a historical cohort of surgical patients, a strategy of attempting ER first reduced morbidity. A randomized trial is warranted to compare ER to laparoscopic surgery for polyps ≥ 4 cm.
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Affiliation(s)
- Milan Patel
- Department of Internal Medicine, Virginia Commonwealth University Health Center, Richmond, USA
| | - Mahfuzul Haque
- Division of Gastroenterology, Durham VA Medical Center, Durham, USA.,Division of Gastroenterology and Hepatology, Duke University Medical Center, Durham, USA
| | - Divyanshoo Kohli
- Division of Gastroenterology, Kansas City VA Medical Center, Kansas City, USA.,Division of Gastroenterology, University of Kansas Medical Center, Kansas City, USA
| | - Pritesh Mutha
- Division of Gastroenterology, Hunter Holmes McGuire VA Medical Center, Richmond, USA.,Division of Gastroenterology and Hepatology, Department of Medicine, Virginia Commonwealth University Health Center, Richmond, USA
| | - Syed A Shah
- Division of Gastroenterology and Hepatology, Department of Medicine, Virginia Commonwealth University Health Center, Richmond, USA.,Department of Surgery, Hunter Holmes McGuire VA Medical Center, Richmond, USA
| | - Leopoldo Fernandez
- Division of Gastroenterology and Hepatology, Department of Medicine, Virginia Commonwealth University Health Center, Richmond, USA.,Department of Surgery, Hunter Holmes McGuire VA Medical Center, Richmond, USA
| | - Alvin Zfass
- Division of Gastroenterology, Hunter Holmes McGuire VA Medical Center, Richmond, USA.,Division of Gastroenterology and Hepatology, Department of Medicine, Virginia Commonwealth University Health Center, Richmond, USA
| | - Tilak Shah
- Division of Gastroenterology, Hunter Holmes McGuire VA Medical Center, Richmond, USA. .,Division of Gastroenterology and Hepatology, Department of Medicine, Virginia Commonwealth University Health Center, Richmond, USA.
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27
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Jang SR, Truong H, Oh A, Choi J, Tramontano AC, Laszkowska M, Hur C. Cost-effectiveness Evaluation of Targeted Surgical and Endoscopic Therapies for Early Colorectal Adenocarcinoma Based on Biomarker Profiles. JAMA Netw Open 2020; 3:e1919963. [PMID: 32150269 PMCID: PMC7063501 DOI: 10.1001/jamanetworkopen.2019.19963] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Colorectal cancer (CRC) is the second leading cause of cancer-related mortality in the United States. The prognosis for patients with CRC varies widely, but new prognostic biomarkers provide the opportunity to implement a more individualized approach to treatment selection. OBJECTIVE To assess the cost-effectiveness of 3 therapeutic strategies, namely, endoscopic therapy (ET), laparoscopic colectomy (LC), and open colectomy (OC), for patients with T1 CRC with biomarker profiles that prognosticate varying levels of tumor progression in the US payer perspective. DESIGN, SETTING, AND PARTICIPANTS In this economic evaluation study, a Markov model was developed for the cost-effectiveness analysis. Risks of all-cause mortality and recurrent cancer after ET, LC, or OC were estimated with a 35-year time horizon. Quality of life was based on EuroQoL 5 Dimensions scores reported in the published literature. Hospital and treatment costs reflected Medicare reimbursement rates. Deterministic and probabilistic sensitivity analyses were performed. Data from patients with T1 CRC and 6 biomarker profiles that included adenomatous polyposis coli (APC), TP53 and/or KRAS, or BRAFV600E were used as inputs for the model. Data analyses were conducted from February 27, 2019, to May 13, 2019. EXPOSURES Endoscopic therapy, LC, and OC. MAIN OUTCOMES AND MEASURES The primary outcomes were unadjusted life-years, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER) between competing treatment strategies. RESULTS Endoscopic therapy had the highest QALYs and the lowest cost and was the dominant treatment strategy for T1 CRC with the following biomarker profiles: BRAFV600E, APC(1)/KRAS/TP53, APC(2) or APC(2)/KRAS or APC(2)/TP53, or APC(1) or APC(1)/KRAS or APC(1)/TP53. The QALYs gained ranged from 16.97 to 17.22, with costs between $68 902.75 and $77 784.53 in these subgroups. For the 2 more aggressive biomarker profiles with worse prognoses (APC(2)/KRAS/TP53 and APCwt [wild type]), LC was the most effective strategy (with 16.45 and 16.61 QALYs gained, respectively) but was not cost-effective. Laparoscopic colectomy cost $65 234.87 for APC(2)/KRAS/TP53 and $71 250.56 for APCwt, resulting in ICERs of $113 290 per QALY and $178 765 per QALY, respectively. CONCLUSIONS AND RELEVANCE This modeling analysis found that ET was the most effective strategy for patients with T1 CRC with less aggressive biomarker profiles. For patients with more aggressive profiles, LC was more effective but was costly, rendering ET the cost-effective option. This study highlights the potential utility of prognostic biomarkers in T1 CRC treatment selection.
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Affiliation(s)
- Se Ryeong Jang
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
- now with College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Han Truong
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Aaron Oh
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Jin Choi
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Angela C. Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Monika Laszkowska
- Department of Medicine, New York Presbyterian/Columbia University Medical Center, New York, New York
| | - Chin Hur
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
- Herbert Irving Comprehensive Cancer Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Medicine, New York Presbyterian/Columbia University Medical Center, New York, New York
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Lee JK, Kidambi TD, Kaltenbach T, Bhat YM, Shergill A, McQuaid KR, Terdiman JP, Soetikno RM. Impact of observational training on endoscopic mucosal resection outcomes and competency for large colorectal polyps: single endoscopist experience. Endosc Int Open 2020; 8:E346-E353. [PMID: 32140557 PMCID: PMC7055616 DOI: 10.1055/a-1107-2711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 12/02/2019] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Endoscopic mucosal resection (EMR) is standard treatment for large colorectal polyps. However, it is a specialized technique with limited data on the effectiveness of training methods to acquire this skill. The aim of this study was to evaluate the impact of observational training on EMR outcomes and competency in an early-stage endoscopist. Patients and methods A single endoscopist completed comprehensive EMR training, which included knowledge acquisition and direct observation of EMR cases, and proctored supervision, during the third year of gastroenterology fellowship. After training, EMR was independently attempted on 142 consecutive, large (i. e., ≥ 20 mm), non-pedunculated colorectal polyps between July 2014 and December 2017 (mean age 61.7 years; mean polyp size 30.4 mm; en-bloc resection 55 %). Surveillance colonoscopy for evaluation of residual neoplasia was available for 86 % of the cases. Three primary outcomes were evaluated: endoscopic assessment of complete resection, rate of adverse events (AEs), and rate of residual neoplasia on surveillance colonoscopy. Results Complete endoscopic resection was achieved in 93 % of cases, the rates of AEs and residual neoplasia were 7.8 % and 7.3 %, respectively. The rate of complete resection remained stable (at 85 % or greater) with increasing experience while rates of AEs and residual neoplasia peaked and decreased after 60 cases. Conclusions An early-stage endoscopist can acquire the skills to perform effective EMR after completing observational training. At least 60 independent EMRs for large colorectal polyps were required to achieve a plateau for clinically meaningful outcomes.
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Affiliation(s)
- Jeffrey K. Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, United States,Kaiser Permanente Division of Research, Oakland, California, United States,Division of Gastroenterology, University of California, San Francisco, San Francisco, California, United States
| | - Trilokesh D. Kidambi
- Division of Gastroenterology, City of Hope National Medical Center, Duarte, California, United States
| | - Tonya Kaltenbach
- San Francisco Veterans Affairs Healthcare System, San Francisco, California, United States,Division of Gastroenterology, University of California, San Francisco, San Francisco, California, United States
| | - Yasser M. Bhat
- Division of Gastroenterology, Palo Alto Medical Foundation, Palo Alto, California, United States
| | - Amandeep Shergill
- San Francisco Veterans Affairs Healthcare System, San Francisco, California, United States,Division of Gastroenterology, University of California, San Francisco, San Francisco, California, United States
| | - Kenneth R. McQuaid
- San Francisco Veterans Affairs Healthcare System, San Francisco, California, United States,Division of Gastroenterology, University of California, San Francisco, San Francisco, California, United States
| | - Jonathan P. Terdiman
- Division of Gastroenterology, University of California, San Francisco, San Francisco, California, United States
| | - Roy M. Soetikno
- San Francisco Veterans Affairs Healthcare System, San Francisco, California, United States,Advanced Gastrointestinal Endoscopy, Mountain View, California, United States
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Kaltenbach T, Anderson JC, Burke CA, Dominitz JA, Gupta S, Lieberman D, Robertson DJ, Shaukat A, Syngal S, Rex DK. Endoscopic Removal of Colorectal Lesions-Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2020; 91:486-519. [PMID: 32067745 DOI: 10.1016/j.gie.2020.01.029] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Tonya Kaltenbach
- Veterans Affairs San Francisco, University California-San Francisco, San Francisco, California.
| | - Joseph C Anderson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; University of Connecticut Health Center, Farmington, Connecticut
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Jason A Dominitz
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - Samir Gupta
- Veterans Affairs San Diego Healthcare System, San Diego, California; University of California-San Diego, San Diego, California
| | | | - Douglas J Robertson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Aasma Shaukat
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota
| | - Sapna Syngal
- Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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Endoscopic Removal of Colorectal Lesions: Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2020; 115:435-464. [PMID: 32058340 DOI: 10.14309/ajg.0000000000000555] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Kaltenbach T, Anderson JC, Burke CA, Dominitz JA, Gupta S, Lieberman D, Robertson DJ, Shaukat A, Syngal S, Rex DK. Endoscopic Removal of Colorectal Lesions-Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2020; 158:1095-1129. [PMID: 32122632 DOI: 10.1053/j.gastro.2019.12.018] [Citation(s) in RCA: 157] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Tonya Kaltenbach
- Veterans Affairs San Francisco, University California-San Francisco, San Francisco, California.
| | - Joseph C Anderson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; University of Connecticut Health Center, Farmington, Connecticut
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Jason A Dominitz
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - Samir Gupta
- Veterans Affairs San Diego Healthcare System, San Diego, California; University of California-San Diego, San Diego, California
| | | | - Douglas J Robertson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Aasma Shaukat
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota
| | - Sapna Syngal
- Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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Raju GS, Lum P, Abu-Sbeih H, Ross WA, Thirumurthi S, Miller E, Lynch P, Lee J, Bhutani MS, Shafi M, Weston B, Rashid A, Wang Y, Chang GJ, Carlson R, Hagan K, Davila M, Stroehlein J. Cap-fitted endoscopic mucosal resection of ≥ 20 mm colon flat lesions followed by argon plasma coagulation results in a low adenoma recurrence rate. Endosc Int Open 2020; 8:E115-E121. [PMID: 32010742 PMCID: PMC6976333 DOI: 10.1055/a-1012-1811] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022] Open
Abstract
Background and study aims Endoscopic mucosal resection (EMR) is increasingly used for the treatment of large colonic polyps (≥ 20 mm). A drawback of EMR is local adenoma recurrence. Therefore, we studied the impact of argon plasma coagulation (APC) of the EMR edge on local adenoma recurrence. Patients and methods This was a retrospective study of patients with laterally spreading tumors (LST) ≥ 20 mm, who underwent EMR from January 2009 to August 2018 and follow-up endoscopic assessment. A cap-fitted endoscope was used to assess completeness of resection by systematically inspecting the EMR defect for any macroscopic disease. This was followed by forced APC of the resection edge followed by clip closure of the defect. Surveillance colonoscopy was performed at 6 months after resection to detect recurrence. Results Two hundred forty-six patients met the inclusion criteria. Most were female (53 %) and white (80 %), with a Median age of 64 years. Median polyp size was 35 mm (interquartile range, 30-45 mm). Most polyps were located in the right colon (77 %) and were removed by piecemeal EMR (70 %). Eleven patients (5 %) had residual tumor at the resection site. Conclusions We observed low adenoma recurrence after argon plasma coagulation of the EMR edge with a cap fitted colonoscope in patients with LST ≥ 20 mm of the colon, which requires further validation in a randomized controlled study.
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Affiliation(s)
- Gottumukkala S. Raju
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Phillip Lum
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Hamzah Abu-Sbeih
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - William A. Ross
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Selvi Thirumurthi
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Ethan Miller
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Patrick Lynch
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Jeffrey Lee
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Manoop S. Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Mehnaz Shafi
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Brian Weston
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Asif Rashid
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - George J. Chang
- Department of Colorectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Richard Carlson
- Department of Colorectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Katherine Hagan
- Department of Colorectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Marta Davila
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - John Stroehlein
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
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Yu JX, Lin JL, Oliver M, Soetikno R, Chang MS, Kwong AJ, Limketkai BN, Bhattacharya J, Kaltenbach T. Trends in EMR for nonmalignant colorectal polyps in the United States. Gastrointest Endosc 2020; 91:124-131.e4. [PMID: 31437455 DOI: 10.1016/j.gie.2019.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 08/05/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Although most large nonpedunculated colorectal lesions can be safely and efficaciously removed using EMR, the use of colectomy for benign colorectal lesions appears to be increasing. The reason(s) is unclear. We aimed to determine the use and adverse events of EMR in the United States. METHODS We used Optum's de-identified Clinformatics Data Mart Database (2003-2016), a database from a large national insurance provider, to identify all colonoscopies performed with either EMR or simple polypectomy on adult patients from January 1, 2011 to December 31, 2015. We measured time trends, regional variation, and adverse event rates. We assessed risk factors for adverse events using multivariate logistic regression. RESULTS The rate of EMR use in the US increased from 1.62% of all colonoscopies in 2011 to 2.48% of colonoscopies in 2015 (P < .001). There were, however, significant regional differences in the use of EMRs, from 2.4% of colonoscopies in the western United States to 2.0% of colonoscopies in the southern United States. Between 2011 and 2015, we found stable rates of perforation, GI bleeding (GIB), infections, and cardiac adverse events and decreasing rates of admissions after EMR. In our multivariate model, EMR was an independent risk factor for adverse events, albeit the rates of adverse events were low (1.35% GIB, .22% perforation). CONCLUSIONS Use of EMR is rising in the United States, although there is significant regional variation. The rates of adverse events after EMR and polypectomies were low and stable, confirming the continued safety of EMR procedures. A better understanding of the regional barriers and facilitators may improve the use of EMR as the standard management for benign colorectal lesions throughout the United States.
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Affiliation(s)
- Jessica X Yu
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Jody L Lin
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Melissa Oliver
- Department of Pediatric Rheumatology, Riley Hospital for Children, IU School of Medicine, Indianapolis, Indiana, USA
| | - Roy Soetikno
- Advanced Gastrointestinal Endoscopy, Mountain View, California, USA
| | - Matthew S Chang
- Department of Gastroenterology, Kaiser Permanente San Francisco, San Francisco, California, USA
| | - Allison J Kwong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Berkeley N Limketkai
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Jay Bhattacharya
- Center for Primary Care and Outcomes Research, Stanford University, Stanford, California, USA
| | - Tonya Kaltenbach
- Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, University of California San Francisco, San Francisco, California, USA
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Ponugoti PL, Broadley HM, Garcia J, Rex DK. Endoscopic management of large ileocecal valve lesions over an 18-year interval. Endosc Int Open 2019; 7:E1646-E1651. [PMID: 31788547 PMCID: PMC6877426 DOI: 10.1055/a-0990-9035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 04/17/2019] [Indexed: 12/13/2022] Open
Abstract
Background and study aims Ileocecal valve (ICV) lesions are challenging to remove endoscopically. Patients and methods This was a retrospective cohort study, performed at an academic tertiary US hospital. Sessile polyps or flat ICV lesions ≥ 20 mm in size referred for endoscopic mucosal resection (EMR) were included. Successful resection rates, complication rates and recurrence were compared to lesions ≥ 20 mm in size not located on the ICV. Results During an 18-year interval, there were 118 ICV lesions ≥ 20 mm with mean size 28.6 mm (44.9 % females; mean age 71.6 years), comprising 9.03 % of all referred polyps. Ninety ICV lesions (76.3 %) were resected endoscopically, compared to 91.3 % of non-ICV lesions ( P < 0.001). However, in the most recent 8 years, successful EMR of ICV lesions increased to 93 %. Conventional adenomas comprised 92.2 % of ICV lesions and 7.8 % were serrated. Delayed hemorrhage and perforation occurred in 3.3 % and 0 % of ICV lesions, respectively, compared to 4.8 % and 0.5 % in the non-ICV group. At first follow-up, rates of residual polyp in the ICV and non-ICV groups were 16.5 % and 13.6 %, respectively ( P = 0.485). At second follow-up residual rates in the ICV and non-ICV lesion groups were 18.6 % and 6.7 %, respectively ( P = .005). Conclusions Large ICV polyps are a common source of tertiary referrals. Over an 18-year experience, risk of EMR for ICV polyps was numerically lower, and risk of recurrence was numerically higher at first follow and significantly higher at second follow-up compared to non-ICV polyps.
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Affiliation(s)
- Prasanna L. Ponugoti
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine
| | - Heather M. Broadley
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine
| | - Jonathan Garcia
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine
| | - Douglas K. Rex
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine,Corresponding author Douglas K. Rex, MD 4100Indiana University Hospital550 North University BoulevardIndianapolis, IN 46202+1-317-948-7057
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Cost Effectiveness of Endoscopic Resection vs Transanal Resection of Complex Benign Rectal Polyps. Clin Gastroenterol Hepatol 2019; 17:2740-2748.e6. [PMID: 30849517 DOI: 10.1016/j.cgh.2019.02.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/14/2019] [Accepted: 02/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Complex benign rectal polyps can be managed with transanal surgery or with endoscopic resection (ER). Though the complication rate after ER is lower than transanal surgery, recurrence is higher. Patients lost to follow up after ER might therefore be at increased risk for rectal cancer. We evaluated the costs, benefits, and cost effectiveness of ER compared to 2 surgical techniques for removing complex rectal polyps, using a 50-year time horizon-this allowed us to capture rates of cancer development among patients lost from follow-up surveillance. METHODS We created a Markov model to simulate the lifetime outcomes and costs of ER, transanal endoscopic microsurgery (TEM), and transanal minimally invasive surgery (TAMIS) for the management of a complex benign rectal polyp. We assessed the effect of surveillance by allowing a portion of the patients to be lost to follow up. We calculated the cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio or each intervention over a 50-year time horizon. RESULTS We found that TEM was slightly more effective than TAMIS and ER (TEM, 19.54 QALYs; TAMIS, 19.53 QALYs; and ER, 19.53 QALYs), but ER had a lower lifetime discounted cost (ER cost $7161, TEM cost $10,459, and TAMIS cost $11,253). TEM was not cost effective compared to ER, with an incremental cost-effectiveness ratio of $485,333/QALY. TAMIS was dominated by TEM. TEM became cost effective when the mortality from ER exceeded 0.63%, or if the loss to follow up rate exceeded 25.5%. CONCLUSIONS Using a Markov model, we found that ER, TEM, and TAMIS have similar effectiveness, but ER is less expensive, in management of benign rectal polyps. As the rate of loss to follow up increases, transanal surgery becomes more effective relative to ER.
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Worland T, Cronin O, Harrison B, Alexander L, Ding N, Ting A, Dimopoulos S, Sykes R, Alexander S. Clinical and financial impacts of introducing an endoscopic mucosal resection service for treatment of patients with large colonic polyps into a regional tertiary hospital. Endosc Int Open 2019; 7:E1386-E1392. [PMID: 31673609 PMCID: PMC6805202 DOI: 10.1055/a-0970-8828] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 06/17/2019] [Indexed: 12/17/2022] Open
Abstract
Background and study aims Endoscopic mucosal resection (EMR) of large sessile or laterally spreading colonic lesions is a safe alternative to surgery. We assessed reductions in Surgical Resection (SR) rates and associated clinical and financial benefits following the introduction of an EMR service to a large regional center. Patients and methods Ongoing prospective intention-to-treat analysis of EMR was undertaken from time of service inception in 2009 to 2017. Retrospective data for SR of large sessile/laterally spreading colonic lesions were collected for the period 4 years before commencement of the EMR service (2005 - 2008) and 9 years after its introduction (2009 - 2017). Results From 2005 to 2008, 32 surgical procedures were performed for non-malignant colonic neoplasia (50 % male, median age 68 years, median Length of Stay (LoS) 10 days). Following the introduction of the EMR service, there was a 56 % reduction in the number of patients referred for surgery (32 surgical procedures, 47 % male, median age 70 years, median LoS 8.5 days). During this period, EMR was successfully performed in 183 patients with 216 lesions resected (60 % male, median age 68 years, median LoS 1 day). Compared to the SR group, the EMR cohort had a lower peri-procedural complication rate (7.7 % vs 54.7 %, P < 0.0001), and shorter average LoS (1 vs 9 days, P < 0.0001). A cost saving of AUD $ 19 543.5 was seen per lesion removed with EMR compared to SR. Conclusions The introduction of a dedicated EMR service into a large regional center as an alternative to SR can lead to a substantial decrease in unnecessary surgery with subsequent clinical and financial benefits.
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Affiliation(s)
| | | | | | | | - Nik Ding
- St Vincent’s Hospital, Melbourne, Australia,University of Melbourne, Melbourne, Australia
| | - Alvin Ting
- University Hospital Geelong, Geelong, Australia,Deakin University, Geelong, Australia
| | | | | | - Sina Alexander
- University Hospital Geelong, Geelong, Australia,Deakin University, Geelong, Australia,Corresponding author Dr. Sina Alexander Department of GastroenterologyBarwon HealthUniversity Hospital GeelongRyrie St.GeelongAustralia 3220
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Prophylactic Snare Tip Soft Coagulation and Its Impact on Adenoma Recurrence After Colonic Endoscopic Mucosal Resection. Dig Dis Sci 2019; 64:3300-3306. [PMID: 31098871 DOI: 10.1007/s10620-019-05666-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 05/07/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Up to 20% of patients can have recurrence of adenomatous tissue at first surveillance study after colon endoscopic mucosal resection of large polyps. AIMS To determine whether an educational intervention discussing thermal ablation of lateral margins of the mucosectomy site of post-endoscopic mucosal resection defect with snare tip soft coagulation (STSC) would decrease adenoma recurrence. METHODS We performed a single-center quality improvement project from November 1, 2016, to November 30, 2017. Gastroenterologists underwent an educational intervention demonstrating the treatment of peripheral margins of mucosectomy site with STSC after standard mucosectomy technique. These cases (intervention group) were compared with consecutive procedures performed prior to commencement of the quality improvement study (pre-intervention group). Patients with large colorectal lesions (≥ 20 mm) were included. RESULTS Of the 120 patients here included, overall demographics of the groups were similar and the most common histology was sessile serrated adenoma (study group 45% vs 32% control group). Adenoma recurrence on intervention group and pre-intervention group was 12% versus 30%; p = 0.01. On univariate analysis, biopsy prior to mucosectomy, intraprocedural bleeding, and application of STSC on mucosectomy defect were the strongest predictors of adenoma recurrence. Adenoma recurrence in the intervention group was significantly lower than in the pre-intervention group in both univariate (odds ratio, 0.3 [95% CI, 0.11-0.80]) and multivariate analyses (odds ratio, 0.2 [95% CI, 0.12-0.92]). CONCLUSIONS The implementation of STSC of post-endoscopic mucosal resection peripheral defects is clinically feasible and significantly decreased adenoma recurrence.
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Dekker E, Tanis PJ, Vleugels JLA, Kasi PM, Wallace MB. Colorectal cancer. Lancet 2019; 394:1467-1480. [PMID: 31631858 DOI: 10.1016/s0140-6736(19)32319-0] [Citation(s) in RCA: 2175] [Impact Index Per Article: 435.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 07/19/2019] [Accepted: 08/15/2019] [Indexed: 02/07/2023]
Abstract
Several decades ago, colorectal cancer was infrequently diagnosed. Nowadays, it is the world's fourth most deadly cancer with almost 900 000 deaths annually. Besides an ageing population and dietary habits of high-income countries, unfavourable risk factors such as obesity, lack of physical exercise, and smoking increase the risk of colorectal cancer. Advancements in pathophysiological understanding have increased the array of treatment options for local and advanced disease leading to individual treatment plans. Treatments include endoscopic and surgical local excision, downstaging preoperative radiotherapy and systemic therapy, extensive surgery for locoregional and metastatic disease, local ablative therapies for metastases, and palliative chemotherapy, targeted therapy, and immunotherapy. Although these new treatment options have doubled overall survival for advanced disease to 3 years, survival is still best for those with non-metastasised disease. As the disease only becomes symptomatic at an advanced stage, worldwide organised screening programmes are being implemented, which aim to increase early detection and reduce morbidity and mortality from colorectal cancer.
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Affiliation(s)
- Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands.
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
| | - Jasper L A Vleugels
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands; Department of Internal Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
| | - Pashtoon M Kasi
- Department of Medical Oncology, University of Iowa, Iowa City, IA, USA
| | - Michael B Wallace
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
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Device assisted enteroscopy in the elderly - A systematic review and meta-analysis. Dig Liver Dis 2019; 51:1249-1256. [PMID: 31036473 DOI: 10.1016/j.dld.2019.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 03/19/2019] [Accepted: 04/01/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Device assisted enteroscopy (DAE) is increasingly being carried out in elderly patients. This provides a challenge due to the underlying varied physiology and comorbidities these patients have. METHODS We performed a systematic literature search for studies on elderly patients undergoing DAE. We calculated the pooled diagnostic (DY) and therapeutic yields (TY), major adverse events, length of small bowel examined and sedation administered. These were also compared to younger patients. RESULTS Fourteen high quality articles on DAE in the elderly were included in this analysis (3289 total, 1712 elderly) patients. Nine of these studies were included in the final meta-analysis (681 elderly, 1577 young patients). The overall DY of DAE, double balloon enterosocpy (DBE) and single balloon enteroscopy (SBE) were 0.68 (p = 0.000001), 1.74 (p = 0.0001) and 1.90 (p = 0.009). The TY of DAE, DBE and SBE were 0.45 (p = 0.00001), 2.20 (p = 0.00001) and 2.36 (p = 0.00001). On comparison of elderly and young patients, DY (1.83; 95% CI: 1.49, 2.24; p = 0.00001) and TY (2.28; 95% CI: 1.79, 2.89) were better in elderly patients. There was no difference in adverse events in both groups (2.16; 95% CI: 0.82, 5.69, p = 0.12). Elderly patients were given less sedation than younger patients during DAE. CONCLUSIONS DAE has a higher DY and TY in the elderly than younger patients. DAE can be safely carried out in the elderly with less sedation.
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Currie AC, Merriman H, Nadia Shah Gilani S, Mackenzie P, McFall MR, Baig MK. Validation of the size morphology site access score in endoscopic mucosal resection of large polyps in a district general hospital. Ann R Coll Surg Engl 2019; 101:558-562. [PMID: 31233327 DOI: 10.1308/rcsann.2019.0068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Polyp assessment is multimodal and is vital prior to endoscopic mucosal resection. The size, morphology, site and access (SMSA) score has been validated in specialist endoscopic institutions. this study investigated the ability of this score to predict incomplete endoscopic resection of large colorectal polyps in a district general hospital. METHODS Consecutive patients undergoing endoscopic mucosal resection of large (≥ 20 mm) colorectal polyps at Worthing Hospital. Clinical, endoscopic and histological data were taken from prospective databases. The primary outcome of the study was to investigate the correlation of the SMSA score with incomplete endoscopic resection. RESULTS Between February 2015 and August 2018, 114 patients underwent colorectal endoscopic mucosal resection. Of these, 67 (59%) were male. The median (interquartile range) age of the study population was 72 years (65-78 years). Some 17 lesions (15%) were pedunculated, 76 (67%) were sessile and 21 were (18%) flat; 84 polyps (77%) were located in the left colon/rectum, with the remainder in the right colon; 51 lesions (45%) were 20-30 mm, 27 (24%) were 30-40 mm and 36 (31%) were greater than 40 mm in diameter. When reclassified into the SMSA score, 9 of the polyps (8%) were level 2, 64 (56%) were level 3 and 41 (36%) were level 4. Incomplete resection was clinically diagnosed in 9/114 (8%). The SMSA score was positively correlated with incomplete endoscopic resection, but not with additional procedure usage, complications or advanced histology. CONCLUSIONS Many patients with large polyps can be managed outside of specialist units. This study has validated that the SMSA score was associated with incomplete endoscopic mucosal resection for large polyps in a district general hospital setting.
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Affiliation(s)
- A C Currie
- Department of General and Colorectal Surgery, Worthing Hospital, Worthing, UK
| | - H Merriman
- Department of General and Colorectal Surgery, Worthing Hospital, Worthing, UK
| | - S Nadia Shah Gilani
- Department of General and Colorectal Surgery, Worthing Hospital, Worthing, UK
| | - P Mackenzie
- Department of General and Colorectal Surgery, Worthing Hospital, Worthing, UK
| | - M R McFall
- Department of General and Colorectal Surgery, Worthing Hospital, Worthing, UK
| | - M K Baig
- Department of General and Colorectal Surgery, Worthing Hospital, Worthing, UK
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Velegraki M, Trikola A, Vasiliadis K, Fragaki M, Mpitouli A, Dimas I, Voudoukis E, Giannikaki E, Kapranou A, Kordelas A, Stefanidis G, Paspatis GA. Endoscopic full-thickness resection of colorectal lesions with the full-thickness resection device: clinical experience from two referral centers in Greece. Ann Gastroenterol 2019; 32:482-488. [PMID: 31474795 PMCID: PMC6686092 DOI: 10.20524/aog.2019.0392] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/22/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Endoscopic full-thickness resection (EFTR) using the full-thickness resection device (FTRD®) is an invasive treatment for colorectal lesions not resectable by conventional endoscopic techniques. This study presents the first Greek experience of the FTRD® procedure, assessing the efficacy and safety of EFTR. Methods: We conducted a retrospective analysis of 17 consecutive patients treated with the FTRD® at 2 referral centers from October 2015 through December 2018. The indications included difficult adenomas (non-lifting and/or at difficult locations), early adenocarcinomas and subepithelial tumors. Primary endpoints were technical success and R0 resection. Results: Technical success and R0 resection were achieved in 82.3% procedures (14/17) and in 87.5% of those with difficult adenomas (8 patients). In the subgroup with carcinomas (n=3), the rate of technical success and R0 resection was 66.6%, while in the subgroup with subepithelial tumors (n=6) the rate was 83.3%. Technical success and R0 resection were significantly lower for lesions >20 mm vs. ≤20 mm (P=0.0429). In the 17 patients a total of 3 adverse events occurred (17.6%) and one of the patients underwent laparoscopic appendectomy because of EFTR around the appendix. Conclusions: Our study showed favorable results concerning EFTR feasibility, efficacy and safety, especially for lesions ≤20 mm, non-lifting adenomas, and subepithelial tumors. Technical success, R0 resection, and adverse events rates were comparable with previously published data. Larger randomized studies are needed to better define the clinical benefit and long-term outcomes of EFTR in selected patients.
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Affiliation(s)
- Magdalini Velegraki
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete (Magdalini Velegraki, Maria Fragaki, Afroditi Mpitouli, Ioannis Dimas, Evangelos Voudoukis, Gregorios A. Paspatis)
| | - Artemis Trikola
- Department of Gastroenterology, Athens Naval Hospital, Athens (Artemis Trikola, Konstantinos Vasiliadis, Gerasimos Stefanidis)
| | - Konstantinos Vasiliadis
- Department of Gastroenterology, Athens Naval Hospital, Athens (Artemis Trikola, Konstantinos Vasiliadis, Gerasimos Stefanidis)
| | - Maria Fragaki
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete (Magdalini Velegraki, Maria Fragaki, Afroditi Mpitouli, Ioannis Dimas, Evangelos Voudoukis, Gregorios A. Paspatis)
| | - Afroditi Mpitouli
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete (Magdalini Velegraki, Maria Fragaki, Afroditi Mpitouli, Ioannis Dimas, Evangelos Voudoukis, Gregorios A. Paspatis)
| | - Ioannis Dimas
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete (Magdalini Velegraki, Maria Fragaki, Afroditi Mpitouli, Ioannis Dimas, Evangelos Voudoukis, Gregorios A. Paspatis)
| | - Evangelos Voudoukis
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete (Magdalini Velegraki, Maria Fragaki, Afroditi Mpitouli, Ioannis Dimas, Evangelos Voudoukis, Gregorios A. Paspatis)
| | - Elpida Giannikaki
- Department of Histopathology, Venizeleion General Hospital, Heraklion, Crete (Elpida Giannikaki)
| | - Amalia Kapranou
- Department of Histopathology, Athens Naval Hospital, Athens (Amalia Kapranou, Athanasios Kordelas), Greece
| | - Athanasios Kordelas
- Department of Histopathology, Athens Naval Hospital, Athens (Amalia Kapranou, Athanasios Kordelas), Greece
| | - Gerasimos Stefanidis
- Department of Gastroenterology, Athens Naval Hospital, Athens (Artemis Trikola, Konstantinos Vasiliadis, Gerasimos Stefanidis)
| | - Gregorios A Paspatis
- Department of Gastroenterology, Venizeleion General Hospital, Heraklion, Crete (Magdalini Velegraki, Maria Fragaki, Afroditi Mpitouli, Ioannis Dimas, Evangelos Voudoukis, Gregorios A. Paspatis)
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Raju G, Lum P, Ross W, Thirumurthi S, Miller E, Lynch P, Lee J, Bhutani MS, Shafi MA, Weston B, Blechacz B, Chang GJ, Hagan K, Rashid A, Davila M, Stroehlein J. Quality of endoscopy reporting at index colonoscopy significantly impacts outcome of subsequent EMR in patients with > 20 mm colon polyps. Endosc Int Open 2019; 7:E361-E366. [PMID: 30834295 PMCID: PMC6395098 DOI: 10.1055/a-0746-3520] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/09/2018] [Indexed: 12/26/2022] Open
Abstract
Background and study aims Endoscopic mucosal resection (EMR) is safe and cost-effective in management of patients with colon polyps. However, very little is known about the actions of the referring endoscopist following identification of these lesions at index colonoscopy, and the impact of those actions on the outcome of subsequent referral for EMR. The aim of this study was to identify practices at index colonoscopy that lead to failure of subsequent EMR. Patients and methods Two hundred and eighty-nine consecutive patients with biopsy-proven non-malignant colon polyps (> 20 mm) referred for EMR were analyzed to identify practices that could be improved from the time of identifying the lesion at index colonoscopy until completion of therapy. Results EMR was abandoned at colonoscopy at the EMR center in 71 of 289 patients (24.6 %). Reasons for abandoning EMR included diagnosis of invasive carcinoma (n = 9; 12.7 %), tethered lesions (n = 21; 29.6 %) from prior endoscopic interventions, and overly large (n = 22; 31 %) and inaccessible lesions (n = 17; 24 %) for complete and safe resection whose details were not recorded in the referring endoscopy report, or polyposis syndromes (n = 2; 2.8 %) that were not recognized. Conclusions In our practice, one in four EMR attempts were abandoned as a result of inadequate diagnosis or management by the referring endoscopist, which could be improved by education on optical diagnosis of polyps, comprehensive documentation of the procedure and avoidance of interventions that preclude resection.
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Affiliation(s)
- Gottumukkala Raju
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States,Corresponding author Gottumukkala Raju The University of Texas MD Anderson Cancer CenterGastroenterology, Hepatology and Nutrition1515 Holcombe BoulevardGI Division – Unit 1466Houston, TX 77030-4009United States+1-713-563-4408
| | - Phillip Lum
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - William Ross
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Selvi Thirumurthi
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Ethan Miller
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Patrick Lynch
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Jeffrey Lee
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Manoop S. Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Mehnaz A. Shafi
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Brian Weston
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Boris Blechacz
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - George J Chang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Katherine Hagan
- Department of Anesthesiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Asif Rashid
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - Marta Davila
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
| | - John Stroehlein
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
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Hillman YJ, Hillman BS, Sejpal DV, Lee C, Miller LS, Benias PC, Trindade AJ. Effect of time of day and daily endoscopic workload on outcomes of endoscopic mucosal resection for large sessile colon polyps. United European Gastroenterol J 2019; 7:146-154. [PMID: 30788127 DOI: 10.1177/2050640618804724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/10/2018] [Indexed: 12/24/2022] Open
Abstract
Background Endoscopic mucosal resection of large non-pedunculated colon polyps is challenging. Objective To determine if the time of day or daily endoscopic workload play a role in outcomes of endoscopic mucosal resection for large non-pedunculated colon polyps greater than 20 mm. Methods This is a retrospective study of patients who underwent endoscopic mucosal resection of large non-pedunculated colon polyps. The time of day and endoscopic workload were compared across the following outcomes: the rate of complete resection of the polyp, the rate of referral for surgery, and the rate of residual neoplasia on follow-up. Results One hundred and three endoscopic mucosal resection procedures were performed. There were no differences in the rates of complete resection (80.8% vs. 70.0%; P = 0.25), the need for surgery (27.4% vs. 33.3%; P = 0.55), and rate of residual neoplasia (24.5% vs. 50.0%; P = 0.07) when comparing the time of day. Colon polyps greater than 40 mm were less likely to be completely resected versus polyps sized 20-39 mm (56.8% vs. 91.9%; P < 0.001). In cases with no residual neoplasia on follow-up, the mean duration for the index procedure was 45.6 minutes versus 60.7 minutes when there was residual neoplasia (P < 0.01). Conclusion The time of day and endoscopic workload does not affect outcomes for endoscopic mucosal resection of large non-pedunculated colon polyps, but the size of large non-pedunculated colon polyps and resection times do.
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Affiliation(s)
- Yonatan J Hillman
- Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, NY, USA
| | - Bari S Hillman
- Steven A. Cohen Military Family Clinic, New York University, New York, USA
| | - Divyesh V Sejpal
- Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, NY, USA
| | - Calvin Lee
- Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, NY, USA
| | - Larry S Miller
- Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, NY, USA
| | - Petros C Benias
- Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, NY, USA
| | - Arvind J Trindade
- Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, NY, USA
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Dattani M, Crane S, Battersby NJ, Di Fabio F, Saunders BP, Dolwani S, Rutter MD, Moran BJ. Variations in the management of significant polyps and early colorectal cancer: results from a multicentre observational study of 383 patients. Colorectal Dis 2018; 20:1088-1096. [PMID: 29999580 DOI: 10.1111/codi.14342] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 07/11/2018] [Indexed: 02/08/2023]
Abstract
AIM The concept of significant polyps and early colorectal cancer (SPECC) encompasses complex polyps not amenable to routine snare polypectomy or where malignancy cannot be excluded. Surgical resection (SR) offers definitive treatment, but is overtreatment for the majority which are benign and amenable to less invasive endoscopic resection (ER). The aim of this study was to investigate variations in the management and outcomes of significant colorectal polyps. METHOD This was a retrospective observational study of significant colorectal polyps, defined as nonpedunculated lesions of ≥ 20 mm size, diagnosed across nine UK hospitals in 2014. Inclusion criteria were endoscopically or histologically benign polyps at biopsy. RESULTS A total of 383 patients were treated by primary ER (87.2%) or SR (12.8%). Overall, 108/383 (28%) polyps were detected in the Bowel Cancer Screening Programme (BCSP). Primary SR was associated with a significantly longer length of stay and major complications (P < 0.01). Of the ER polyps, 290/334 (86.8%) patients were treated without undergoing surgery. The commonest indication for secondary surgery was unexpected polyp cancer, and of these cases 60% had no residual cancer in the specimen. Incidence of unexpected cancer was 10.7% (n = 41) and was similar between ER and SR groups (P = 0.11). On multivariate analysis, a polyp size of > 30 mm and non-BCSP status were independent risk factors for primary SR [OR 2.51 (95% CI 1.08-5.82), P = 0.03]. CONCLUSION ER is safe and feasible for treating significant colorectal polyps. Robust accreditation within the BCSP has led to improvements in management, with lower rates of SR compared with non-BCSP patients. Standardization, training in polyp assessment and treatment within a multidisciplinary team may help to select appropriate treatment strategies and improve outcomes.
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Affiliation(s)
- M Dattani
- Pelican Cancer Foundation, Basingstoke, UK
| | - S Crane
- Pelican Cancer Foundation, Basingstoke, UK
| | - N J Battersby
- Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - F Di Fabio
- Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - B P Saunders
- St Mark's Hospital and Academic Institute, London, UK
| | - S Dolwani
- School of Medicine, Cardiff University, Cardiff, UK
| | - M D Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK
| | - B J Moran
- Basingstoke and North Hampshire Hospital, Basingstoke, UK
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Safe and Effective Endoscopic Resection of Massive Colorectal Adenomas ≥8 cm in a Tertiary Referral Center. Dis Colon Rectum 2018; 61:955-963. [PMID: 29944575 DOI: 10.1097/dcr.0000000000001144] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endoscopic resection of large colorectal lesions is well reported and is the first line of treatment for all noninvasive colorectal neoplasms in many centers, but little is known about the outcomes of endoscopic resection of truly massive colorectal lesions ≥8 cm. OBJECTIVE We report on the outcomes of endoscopic resection for massive (≥8 cm) colorectal adenomas and compare the outcomes with resection of large (2.0-7.9 cm) lesions. DESIGN This was a retrospective study. SETTINGS The study was conducted in a tertiary referral unit for interventional endoscopy. PATIENTS A total of 435 endoscopic resections of large colorectal polyps (≥2 cm) were included, of which 96 were ≥8 cm. MAIN OUTCOME MEASURES Outcomes included initial successful resection, complications, recurrence, surgery, and hospital admission. RESULTS Endoscopic resection was successful for 91 of 96 massive lesions (≥8 cm). Mean size was 10.1 cm (range, 8-16 cm). A total of 75% had previous attempts at resection or heavy manipulation before referral. Thirty two were resected using endoscopic submucosal dissection or hybrid endoscopic submucosal dissection and the rest using piecemeal endoscopic mucosal resection. No patients required surgery for a perforation. Five patients had postprocedural bleeding. There were 25 recurrences: 2 were treated with transanal endoscopic microsurgery, 2 with right hemicolectomy, and the rest with endoscopic resection. Compared with patients with large lesions, more patients with massive adenomas had complications (19.8% versus 3.3%), required admission (39.6% versus 11.0%), developed recurrence (30.8% versus 9.9%), or required surgery for recurrence (5.0% versus 0.8%). LIMITATIONS This was a retrospective study. CONCLUSIONS Endoscopic resection of massive colorectal adenomas ≥8 cm is achievable with few significant complications, and the majority of patients avoid surgery. Systematic assessment is required to appropriately select patients for endoscopic resection, which should be performed in specialist units. See Video Abstract at http://links.lww.com/DCR/A653.
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Schmidt A, Beyna T, Schumacher B, Meining A, Richter-Schrag HJ, Messmann H, Neuhaus H, Albers D, Birk M, Thimme R, Probst A, Faehndrich M, Frieling T, Goetz M, Riecken B, Caca K. Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications. Gut 2018; 67:1280-1289. [PMID: 28798042 DOI: 10.1136/gutjnl-2016-313677] [Citation(s) in RCA: 181] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 06/14/2017] [Accepted: 07/06/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Endoscopic full-thickness resection (EFTR) is a novel treatment of colorectal lesions not amenable to conventional endoscopic resection. The aim of this prospective multicentre study was to assess the efficacy and safety of the full-thickness resection device. DESIGN 181 patients were recruited in 9 centres with the indication of difficult adenomas (non-lifting and/or at difficult locations), early cancers and subepithelial tumours (SET). Primary endpoint was complete en bloc and R0 resection. RESULTS EFTR was technically successful in 89.5%, R0 resection rate was 76.9%. In 127 patients with difficult adenomas and benign histology, R0 resection rate was 77.7%. In 14 cases, lesions harboured unsuspected cancer, another 15 lesions were primarily known as cancers. Of these 29 cases, R0 resection was achieved in 72.4%; 8 further cases had deep submucosal infiltration >1000 µm. Therefore, curative resection could only be achieved in 13/29 (44.8%). In the subgroup with SET (n=23), R0 resection rate was 87.0%. In general, R0 resection rate was higher with lesions ≤2 cm vs >2 cm (81.2% vs 58.1%, p=0.0038). Adverse event rate was 9.9% with a 2.2% rate of emergency surgery. Three-month follow-up was available from 154 cases and recurrent/residual tumour was evident in 15.3%. CONCLUSION EFTR has a reasonable technical efficacy especially in lesions ≤2 cm with acceptable complication rates. Curative resection rate for early cancers was too low to recommend its primary use in this indication. Further comparative studies have to show the clinical value and long-term outcome of EFTR in benign colorectal lesions. TRIAL REGISTRATION NUMBER NCT02362126; Results.
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Affiliation(s)
- Arthur Schmidt
- Department of Gastroenterology, Klinikum Ludwigsburg, University of Heidelberg, Ludwigsburg, Germany.,Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Torsten Beyna
- Department of Internal Medicine and Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Germany
| | - Brigitte Schumacher
- Department of Internal Medicine and Gastroenterology, Elisabeth Hospital, Essen, Germany
| | | | - Hans-Juergen Richter-Schrag
- Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Helmut Messmann
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Horst Neuhaus
- Department of Internal Medicine and Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Germany
| | - David Albers
- Department of Internal Medicine and Gastroenterology, Elisabeth Hospital, Essen, Germany
| | - Michael Birk
- Department of Gastroenterology, University Hospital, Ulm, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Probst
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Martin Faehndrich
- Department of Gastroenterology, Klinikum Dortmund, Dortmund, Germany
| | - Thomas Frieling
- Department of Gastroenterology, Helios Klinikum Krefeld, Krefeld, Germany
| | - Martin Goetz
- Department of Gastroenterology, University Hospital of Tuebingen, Tuebingen, Germany
| | - Bettina Riecken
- Department of Gastroenterology, Klinikum Ludwigsburg, University of Heidelberg, Ludwigsburg, Germany
| | - Karel Caca
- Department of Gastroenterology, Klinikum Ludwigsburg, University of Heidelberg, Ludwigsburg, Germany
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Stier MW, Chapman CG, Kreitman A, Hart JA, Xiao SY, Siddiqui UD, Waxman I. Dissection-enabled scaffold-assisted resection (DeSCAR): a novel technique for resection of residual or non-lifting GI neoplasia of the colon (with video). Gastrointest Endosc 2018; 87:843-851. [PMID: 29158178 DOI: 10.1016/j.gie.2017.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 11/09/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS As a result of previous manipulation or submucosal invasion, GI lesions referred for EMR frequently have flat areas of visible tissue that cannot be snared. Current methods for treating residual tissue may lead to incomplete eradication or not allow complete tissue sampling for histologic evaluation. Our aim is to describe dissection-enabled scaffold-assisted resection (DeSCAR), a new technique combining circumferential ESD with EMR for removal of superficial non-lifting or residual "islands" with suspected submucosal involvement/fibrosis. METHODS From 2015 to 2017, lesions referred for EMR were retrospectively reviewed. Cases were identified where lifting and/or snaring of the lesion was incomplete and the DeSCAR technique was undertaken. Cases were reviewed for location, previous manipulation, rates of successful hybrid resection, and adverse events. RESULTS Twenty-nine lesions underwent DeSCAR because of non-lifting or residual "islands" of tissue. Fifty-two percent of the patients were male and 48% were female; average age was 66 years (standard deviation ±9.9 years). Lesions were located in the cecum (n = 10), right side of the colon (n = 12), left side of the colon (n = 4), and rectum (n = 3). Average size was 31 mm (standard deviation ±20.6 mm). Previous manipulation had occurred in 28 of 29 cases (83% biopsy, 34% resection attempt, 52% tattoo). The technical success rate for resection of non-lifting lesions was 100%. There was one episode of delayed bleeding but no other adverse events. CONCLUSIONS DeSCAR is a feasible and safe alternative to argon plasma coagulation and avulsion for the endoscopic management of non-lifting or residual GI lesions, providing en bloc resection of tissue for histologic review. Further studies are needed to demonstrate long-term eradication and for comparison with other methods.
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Affiliation(s)
- Matthew W Stier
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, Illinois, USA
| | - Christopher G Chapman
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, Illinois, USA
| | - Allie Kreitman
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, Illinois, USA
| | - John A Hart
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, Illinois, USA
| | - Shu-Yuan Xiao
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, Illinois, USA
| | - Uzma D Siddiqui
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, Illinois, USA
| | - Irving Waxman
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, Illinois, USA
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Repici A, Hassan C. Postsurgery risk for nonmalignant colorectal polyps: the ultimate call. Gastrointest Endosc 2018; 87:251-253. [PMID: 29241853 DOI: 10.1016/j.gie.2017.10.003] [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: 10/01/2017] [Accepted: 10/02/2017] [Indexed: 02/08/2023]
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Kandel P, Wallace MB. Colorectal endoscopic mucosal resection (EMR). Best Pract Res Clin Gastroenterol 2017; 31:455-471. [PMID: 28842056 DOI: 10.1016/j.bpg.2017.05.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 05/28/2017] [Indexed: 01/31/2023]
Abstract
Colonoscopy has the benefit of detecting and treating precancerous adenomatous polyps and thus reduces mortality associated with CRC. Screening colonoscopy is the keystone for prevention of colorectal cancer. Over the last 20 years there has been increased in the management of large colorectal polyps from surgery to endoscopic removal techniques which is less invasive. Traditionally surgical resection was the treatment of choice for many years for larger polyps but colectomy poses significant morbidity of 14-46% and mortality of up to 7%. There are several advantages of endoscopic resection technique over surgery; it is less invasive, less expensive, has rapid recovery, and preserves the normal gut functions. In addition patient satisfaction and efficacy of EMR is higher with minor complications. Thus, this has facilitated the development of advanced resection technique for the treatment of large colorectal polyps called as endoscopic mucosal resection (EMR).
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Affiliation(s)
- Pujan Kandel
- Department of Gastroenterology and Hepatology Mayo Clinic Florida 4500 San Pablo Road Jacksonville, FL 32224, USA
| | - Michael B Wallace
- Department of Gastroenterology and Hepatology Mayo Clinic Florida 4500 San Pablo Road Jacksonville, FL 32224, USA.
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Underwater endoscopic mucosal resection is associated with fewer recurrences and earlier curative resections compared to conventional endoscopic mucosal resection for large colorectal polyps. Surg Endosc 2017; 31:4174-4183. [PMID: 28342125 DOI: 10.1007/s00464-017-5474-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 02/15/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Studies comparing the efficacy and safety of conventional saline-assisted piecemeal endoscopic mucosal resection (EMR) to underwater EMR (UEMR) without submucosal lifting of colorectal polyps are lacking. The objective of this study was to compare the efficacy and safety of EMR to UEMR of large colorectal polyps. METHODS Two hundred eighty-nine colorectal polyps were removed by a single endoscopist from 7/2007 to 2/2015 using EMR or UEMR. 135 polyps (EMR: 62, UEMR: 73) that measured ≥15 mm and had not undergone prior attempted polypectomy were evaluated for rates of complete macroscopic resection and adverse events. 101 of these polyps (EMR: 46, UEMR: 55) had at least 1 follow-up colonoscopy and were studied for rates of recurrence and the number of procedures required to achieve curative resection. RESULTS The rate of complete macroscopic resection was higher following UEMR compared to EMR (98.6 vs. 87.1%, p = 0.012). UEMR had a lower recurrence rate at the first follow-up colonoscopy compared to EMR (7.3 vs. 28.3%, OR 5.0 for post-EMR recurrence, 95% CI: [1.5, 16.5], p = 0.008). UEMR required fewer procedures to reach curative resection than EMR (mean of 1.0 vs. 1.3, p = 0.002). There was no significant difference in rates of adverse events. CONCLUSIONS UEMR appears superior to EMR for the removal of large colorectal polyps in terms of rates of complete macroscopic resection and recurrent (or residual) abnormal tissue. Compared to conventional EMR, UEMR may offer increased procedural effectiveness without compromising safety in the removal of large colorectal polyps without prior attempted resection.
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