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von Renteln D, Djinbachian R, Benard F, Barkun AN, Bouin M, Bouchard S, Deslandres É, Panzini B, Sidani S, Leduc R, Jobse BC, Pohl H. Incomplete resection of colorectal polyps of 4-20 mm in size when using a cold snare, and its associated factors. Endoscopy 2023; 55:929-937. [PMID: 36377124 DOI: 10.1055/a-1978-3277] [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: 11/17/2022]
Abstract
BACKGROUND : Cold snare polypectomy (CSP) is increasingly used for polypectomy and is recommended as the first-line modality for small (< 10 mm) polyps. This study aimed to evaluate incomplete resection rates (IRRs) when using CSP for colorectal polyps of 4-20 mm. METHODS : Adults (45-80 years) undergoing screening, surveillance, or diagnostic colonoscopy and CSP by one of nine endoscopists were included. The primary outcome was the IRR for colorectal polyps of 4-20 mm, defined as the presence of polyp tissue in marginal biopsies after resection of serrated polyps or adenomas. Secondary outcomes included the IRR for serrated polyps, ease of resection, and complications. RESULTS: 413 patients were included (mean age 63; 48 % women) and 182 polyps sized 4-20 mm were detected and removed by CSP. CSP required conversion to hot snare resection in < 1 % of polyps of < 10 mm and 44 % of polyps sized 10-20 mm. The IRRs for polyps < 10 mm and ≥ 10 mm were 18 % and 21 %. The IRR was higher for serrated polyps (26 %) compared with adenomas (16 %). The IRR was higher for flat (IIa) polyps (odds ratio [OR] 2.9, 95 %CI 1.1-7.4); and when resection was judged as difficult (OR 4.2, 95 %CI 1.5-12.1), piecemeal resection was performed (OR 6.6, 95 %CI 2.0-22.0), or visible residual polyp was present after the initial resection (OR 5.4, 95 %CI 2.0-14.9). Polyp location, use of a dedicated cold snare, and submucosal injection were not associated with incomplete resection. Intraprocedural bleeding requiring endoscopic intervention occurred in 4.7 %. CONCLUSIONS : CSP for polyps of 4-9 mm is safe and feasible; however, for lesions ≥ 10 mm, CSP failure occurs frequently, and the IRR remains high even after technical success. Incomplete resection was associated with flat polyps, visual residual polyp, piecemeal resection, and difficult polypectomies.
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Affiliation(s)
- Daniel von Renteln
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Roupen Djinbachian
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Florence Benard
- Division of General Surgery, Montreal University Hospital Center (CHUM), Montreal, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Mickael Bouin
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Simon Bouchard
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Érik Deslandres
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Benoit Panzini
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Sacha Sidani
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Raymond Leduc
- Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Bruce C Jobse
- Department of Veterans Affairs Medical Center, White River Junction, Vermont, and Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Heiko Pohl
- Department of Veterans Affairs Medical Center, White River Junction, Vermont, and Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
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Lao W, Prasoon P, Cao G, Tan LT, Dai S, Devadasar GH, Huang X. Risk factors for incomplete polyp resection during colonoscopy. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2021. [DOI: 10.1016/j.lers.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Serna N, Carratalá JV, Conchillo-Solé O, Martínez-Torró C, Unzueta U, Mangues R, Ferrer-Miralles N, Daura X, Vázquez E, Villaverde A. Antibacterial Activity of T22, a Specific Peptidic Ligand of the Tumoral Marker CXCR4. Pharmaceutics 2021; 13:1922. [PMID: 34834337 PMCID: PMC8621837 DOI: 10.3390/pharmaceutics13111922] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/21/2021] [Accepted: 11/05/2021] [Indexed: 12/13/2022] Open
Abstract
CXCR4 is a cytokine receptor used by HIV during cell attachment and infection. Overexpressed in the cancer stem cells of more than 20 human neoplasias, CXCR4 is a convenient antitumoral drug target. T22 is a polyphemusin-derived peptide and an effective CXCR4 ligand. Its highly selective CXCR4 binding can be exploited as an agent for the cell-targeted delivery and internalization of associated antitumor drugs. Sharing chemical and structural traits with antimicrobial peptides (AMPs), the capability of T22 as an antibacterial agent remains unexplored. Here, we have detected T22-associated antimicrobial activity and biofilm formation inhibition over Escherichia coli, Staphylococcus aureus and Pseudomonas aeruginosa, in a spectrum broader than the reference AMP GWH1. In contrast to GWH1, T22 shows neither cytotoxicity over mammalian cells nor hemolytic activity and is active when displayed on protein-only nanoparticles through genetic fusion. Under the pushing need for novel antimicrobial agents, the discovery of T22 as an AMP is particularly appealing, not only as its mere addition to the expanding catalogue of antibacterial drugs. The recognized clinical uses of T22 might allow its combined and multivalent application in complex clinical conditions, such as colorectal cancer, that might benefit from the synchronous destruction of cancer stem cells and local bacterial biofilms.
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Affiliation(s)
- Naroa Serna
- Institut de Biotecnologia i de Biomedicina, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain; (N.S.); (J.V.C.); (O.C.-S.); (C.M.-T.); (N.F.-M.); (E.V.)
- Departament de Genètica i de Microbiologia, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain;
- CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 28029 Madrid, Spain;
| | - José Vicente Carratalá
- Institut de Biotecnologia i de Biomedicina, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain; (N.S.); (J.V.C.); (O.C.-S.); (C.M.-T.); (N.F.-M.); (E.V.)
- Departament de Genètica i de Microbiologia, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain;
- CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 28029 Madrid, Spain;
| | - Oscar Conchillo-Solé
- Institut de Biotecnologia i de Biomedicina, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain; (N.S.); (J.V.C.); (O.C.-S.); (C.M.-T.); (N.F.-M.); (E.V.)
- Departament de Genètica i de Microbiologia, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain;
| | - Carlos Martínez-Torró
- Institut de Biotecnologia i de Biomedicina, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain; (N.S.); (J.V.C.); (O.C.-S.); (C.M.-T.); (N.F.-M.); (E.V.)
| | - Ugutz Unzueta
- Departament de Genètica i de Microbiologia, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain;
- CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 28029 Madrid, Spain;
- Biomedical Research Institute Sant Pau (IIB-Sant Pau), Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain
- Josep Carreras Research Institute, 08916 Barcelona, Spain
| | - Ramón Mangues
- CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 28029 Madrid, Spain;
- Biomedical Research Institute Sant Pau (IIB-Sant Pau), Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain
- Josep Carreras Research Institute, 08916 Barcelona, Spain
| | - Neus Ferrer-Miralles
- Institut de Biotecnologia i de Biomedicina, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain; (N.S.); (J.V.C.); (O.C.-S.); (C.M.-T.); (N.F.-M.); (E.V.)
- Departament de Genètica i de Microbiologia, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain;
- CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 28029 Madrid, Spain;
| | - Xavier Daura
- Institut de Biotecnologia i de Biomedicina, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain; (N.S.); (J.V.C.); (O.C.-S.); (C.M.-T.); (N.F.-M.); (E.V.)
- CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 28029 Madrid, Spain;
- Catalan Institution for Research and Advanced Studies (ICREA), 08010 Barcelona, Spain
| | - Esther Vázquez
- Institut de Biotecnologia i de Biomedicina, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain; (N.S.); (J.V.C.); (O.C.-S.); (C.M.-T.); (N.F.-M.); (E.V.)
- Departament de Genètica i de Microbiologia, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain;
- CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 28029 Madrid, Spain;
| | - Antonio Villaverde
- Institut de Biotecnologia i de Biomedicina, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain; (N.S.); (J.V.C.); (O.C.-S.); (C.M.-T.); (N.F.-M.); (E.V.)
- Departament de Genètica i de Microbiologia, Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain;
- CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 28029 Madrid, Spain;
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Schluckebier D, Afzal NA, Thomson M. Therapeutic Upper Gastrointestinal Endoscopy in Pediatric Gastroenterology. Front Pediatr 2021; 9:715912. [PMID: 35280448 PMCID: PMC8913901 DOI: 10.3389/fped.2021.715912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 12/13/2021] [Indexed: 11/25/2022] Open
Abstract
This paper seeks to give a broad overview of pediatric upper gastrointestinal (GI) pathologies that we are now able to treat endoscopically, acquired or congenital, and we hope this delivers the reader an impression of what is increasingly available to pediatric endoscopists and their patients.
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Affiliation(s)
- Dominique Schluckebier
- Pediatric Gastroenterology, Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, United Kingdom
| | - Nadeem Ahmad Afzal
- Department of Paediatrics, Southampton Children's Hospital, Southampton, United Kingdom
| | - Mike Thomson
- Pediatric Gastroenterology, Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, United Kingdom
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Djinbachian R, Iratni R, Durand M, Marques P, von Renteln D. Rates of Incomplete Resection of 1- to 20-mm Colorectal Polyps: A Systematic Review and Meta-Analysis. Gastroenterology 2020; 159:904-914.e12. [PMID: 32437747 DOI: 10.1053/j.gastro.2020.05.018] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 04/29/2020] [Accepted: 05/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Incomplete resection of neoplastic colorectal polyps can result in postcolonoscopy colorectal cancer. We performed a systematic review and meta-analysis to determine the incomplete resection rate (IRR) of colorectal polyps and associated factors. METHODS We searched MEDLINE, EMBASE, EBM Reviews, and CINAHL to identify full-text articles that reported IRRs of polyps 1 to 20 mm, published until March 2019. Exclusion criteria were studies of inflammatory bowel disease cohorts, referrals for difficult polypectomy, polyp sizes larger than 20 mm, and endoscopic submucosal resection and/or dissection as polypectomy approaches. IRRs were calculated based on findings from biopsies taken at polypectomy sites or assessments of margins of resected polyps. The primary outcome was IRR for snare removal of polyps 1 to 20 mm. Secondary outcomes included IRR for polyps 1 to 10 mm and 10 to 20 mm, IRR for hot and cold snare removal of polyps 1 to 10 mm and 10 to 20 mm, IRR of snare removal with or without submucosal injection, and IRR for forceps and cold snare removal of polyps 1 to 5 mm. RESULTS We identified 6148 reports and used 32 studies, with a total of 9282 polyps, in our quantitative analysis. The IRR for snare removal of polyps 1 to 20 mm was 13.8% (95% confidence interval [CI] 10.3-17.3; 13 studies, 5128 polypectomies). IRRs were 15.9% for snare removal of polyps 1 to 10 mm (95% CI 9.6-22.1; 9 studies, 2531 polypectomies) and 20.8% for snare removal of polyps 10 to 20 mm (95% CI 12.9-28.8; 6 studies, 412 polypectomies). The IRR for hot snare removal of polyps 1 to 10 mm was 14.2% (95% CI 5.2-23.2) vs 17.3% for cold snare polypectomy (95% CI 14.3‒20.3). The IRR for forceps removal of polyps 1 to 5 mm was 9.9% (95% CI 7.1-13.0) vs 4.4% for snare polypectomy (95% CI 2.9-6.1). CONCLUSIONS In a systematic review and meta-analysis, we found that colorectal polyps 1 to 20 mm are frequently incompletely resected, and that risk increases for polyps 10 mm or larger. There is no difference in IRRs of cold vs hot snares for polyps 1 to 10 mm. Snare polypectomy should be used over forceps for polyps 1 to 5 mm.
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Affiliation(s)
- Roupen Djinbachian
- Division of Internal Medicine, Montreal University Hospital Center (CHUM), Montreal, Canada; Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Ryma Iratni
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada; Faculty of Medicine, University of Montreal, Montreal, Canada
| | - Madeleine Durand
- Division of Internal Medicine, Montreal University Hospital Center (CHUM), Montreal, Canada; Montreal University Hospital Research Center (CRCHUM), Montreal, Canada
| | - Paola Marques
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada; Bahia State University (UNEB), Salvador, Brazil
| | - Daniel von Renteln
- Montreal University Hospital Research Center (CRCHUM), Montreal, Canada; Division of Gastroenterology, Montreal University Hospital Center (CHUM), Montreal, Canada.
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O’Morain NR, Syafiq MI, Shahin A, Ryan B, Crowther S, McNamara D. Dye-based chromoendoscopy following polypectomy reduces incomplete polyp resection. Endosc Int Open 2020; 8:E13-E19. [PMID: 31921979 PMCID: PMC6949170 DOI: 10.1055/a-1024-3759] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 07/29/2019] [Indexed: 02/07/2023] Open
Abstract
Background and study aims The completeness of a polyp resection is an important determinant of quality in colonoscopy, and may reduce incidence of interval cancers. Incomplete resection rates (IRR) vary widely and range from 6.5 % to 22.7 %. Residual disease is more likely with larger polyps, for sessile serrated adenomas, and with more proximal lesions. Chromoendoscopy is increasingly employed in lesion detection. The aims of this study were to assess local IRR, and to determine whether chromoendoscopy could correctly identify residual disease post polypectomy. Patients and methods This was a prospective study examining post polypectomy sites. Chromoendoscopy (0.13 % indigo carmine) was applied to resection bases to identify residual disease. Targeted base biopsies were taken from identified residual disease (positive group) or random base biopsies were taken when a clear base was visualised (negative group). Overall rates of incomplete resection were documented. Reported rates post chromoendoscopy and actual histological rates were documented and compared. Results A total of 102 polyps were identified for inclusion, of which 15 % (n = 16) were excluded. Resection quality was evaluated in 86 polyps of 61 patients (female n = 33 54 %; mean Age 62.3 years). Polyps were mainly removed by cold snare (n = 71, 82.5 %). Most polyps (n = 58, 67 %) measured between 5 to 10 mm. Polyps were largely located in the right colon (n = 57, 66 %). Overall histological residual disease occurred in 17 /86 (19.6 %). Chromoendoscopy correctly identified residual disease in 13 of 17 bases (76.5 %). Only four of /86 (4.6 %) of polyp bases were missclassified post-chromoendoscopy (odds ratio 0.284 (95 % CI 0.0857-0.9409), P = 0.03). Conclusion Indigo carmine chromoendoscopy improves early detection of residual disease post polypectomy, reducing incomplete resection rates.
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Affiliation(s)
- Neil R. O’Morain
- Department of Gastroenterology and Clinical Medicine, Tallaght University Hospital, Trinity College Dublin,Trinity Academic Gastroenterology Group, Tallaght University Hospital, Trinity College Dublin
| | - Mohd I. Syafiq
- Department of Gastroenterology and Clinical Medicine, Tallaght University Hospital, Trinity College Dublin,Trinity Academic Gastroenterology Group, Tallaght University Hospital, Trinity College Dublin
| | - Ammar Shahin
- Department of Gastroenterology and Clinical Medicine, Tallaght University Hospital, Trinity College Dublin
| | - Barbara Ryan
- Department of Gastroenterology and Clinical Medicine, Tallaght University Hospital, Trinity College Dublin,Trinity Academic Gastroenterology Group, Tallaght University Hospital, Trinity College Dublin
| | - Stephen Crowther
- Department of Histopathology, Tallaght University Hospital, Trinity College Dublin, Ireland
| | - Deirdre McNamara
- Department of Gastroenterology and Clinical Medicine, Tallaght University Hospital, Trinity College Dublin,Trinity Academic Gastroenterology Group, Tallaght University Hospital, Trinity College Dublin
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EMR is superior to rectal suction biopsy for analysis of enteric ganglia in constipation and dysmotility. Gastrointest Endosc 2018; 87:876-880. [PMID: 28893560 PMCID: PMC5817021 DOI: 10.1016/j.gie.2017.08.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/27/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Patients with chronic constipation or motility disorders may be referred for rectal suction biopsy (RSB) to rule out Hirschsprung's disease (HD). RSB may not be successful beyond infancy because of the increased thickness of the rectal mucosa. EMR could improve the diagnostic yield for HD when compared with traditional RSB because larger and deeper samples are acquired for analysis. METHODS In this prospective, single-center study, patients referred for RSB were offered enrollment for concurrent EMR. Specimens were analyzed pathologically for size, submucosal ganglionic tissue, and acetylcholinesterase or calretinin staining. Biopsy results were compared with transit studies, anorectal manometry, and constipation severity through validated questionnaires. RESULTS Seventeen patients (2 male, 15 female; mean age, 35.8 years; range, 22-61 years) were enrolled in the study from 2008 to 2014. All patients underwent anorectal manometry (88% with anorectal dysfunction, 68% with outlet obstruction) and transit studies (41% with delayed transit). There were no reports of adverse events from the RSB and EMR procedures. The RSB sample volumes were significantly lower than the EMR sample volumes (0.023 cm3 vs 0.26 cm3, P = .001). There was diagnostic tissue for submucosal visualization by RSB in 53% (9/17) of cases compared with 100% (17/17) with EMR (P = .003). No cases of HD were diagnosed by RSB; one patient had rare ganglions observed by EMR. CONCLUSIONS EMR provides greater tissue volume and can improve the characterization of ganglion cells in rectal tissue compared with RSB in patients with moderate to severe constipation with suspected HD.
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Xu JF, Yang L, Jin P, Sheng JQ. Endoscopic Approach for Superficial Colorectal Neoplasms. Gastrointest Tumors 2016; 3:69-80. [PMID: 27904859 DOI: 10.1159/000447128] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 05/26/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is the third most commonly diagnosed cancer in males and the second in females, with an estimated 1.4 million cases and 693,900 deaths in 2012. Colonoscopy is the cornerstone for the detection and prevention of CRC. In addition, endoscopic treatment for CRC at an early stage can effectively improve patients' quality of life and cure rate. SUMMARY This review focuses on endoscopic approaches, including white light endoscopy, chromoendoscopy, magnifying endoscopy and therapeutic endoscopy, for the evaluation and treatment of superficial colorectal neoplasms. KEY MESSAGE Understanding the preoperative evaluation, indications and techniques of endoscopic mucosal resection/endoscopic submucosal dissection as well as postoperative surveillance for superficial colorectal neoplasms is critical for providing appropriate management to the patients. PRACTICAL IMPLICATIONS Endoscopic therapy, a method preserving organ function and improving quality of life, is a widely applied microinvasive treatment for superficial colorectal neoplasms. This review describes the basics and developments of endoscopic approaches and may facilitate daily practice for superficial colorectal neoplasms.
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Affiliation(s)
- Jun-Feng Xu
- People's Liberation Army General Hospital, Beijing, China
| | - Lang Yang
- Department of Gastroenterology, PLA Army General Hospital, Beijing, China
| | - Peng Jin
- Department of Gastroenterology, PLA Army General Hospital, Beijing, China
| | - Jian-Qiu Sheng
- Department of Gastroenterology, PLA Army General Hospital, Beijing, China
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Abstract
Appropriate endoscopic resection for colorectal polyps can present a challenge to endoscopists, as these lesions may harbor malignancy. With recent advances in endoscopy, however, we are now entering an exciting frontier of endoscopic therapy for gastrointestinal lesions. These techniques include endoluminal mucosal resection and endoscopic submucosal dissection, which may be utilized on several colonic lesions. This article will discuss these principle endoscopic techniques, their outcomes, and briefly highlight their influence on endoscopic interventions, including transanal endoscopic microsurgery and natural orifice transluminal endoscopic surgery.
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Affiliation(s)
- Katherine A Kelley
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon
| | - V Liana Tsikitis
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon
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Kim B, Kim YH, Park SJ, Cheon JH, Kim TI, Kim WH, Kim H, Hong SP. Probe-based confocal laser endomicroscopy for evaluating the submucosal invasion of colorectal neoplasms. Surg Endosc 2016; 31:594-601. [PMID: 27324335 DOI: 10.1007/s00464-016-5003-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 05/23/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Probe-based confocal laser endomicroscopy (pCLE) is a novel method for in vivo histological analysis of colorectal neoplasm mucosa, which provides meaningful information for the development of adequate therapeutic strategies. However, the in vivo histology of colorectal neoplasm submucosa has not been studied. We assessed the feasibility and safety of pCLE for evaluating colorectal submucosa, and identified and validated diagnostic criteria for submucosal carcinoma infiltration. METHODS From March to July 2014, 83 pCLE videos of 51 lesions in 31 patients who underwent scheduled colonoscopic procedures for the removal of colorectal neoplasms were acquired consecutively. During the procedures, pCLE videos of the lesions and biopsy samples for histopathological analysis were acquired. Final histopathological results were used as the gold standard. RESULTS Based on the confocal pattern, we classified colorectal submucosa findings as negative (superficial submucosa, deep submucosa, and submucosa with fibrosis) or indicative of carcinoma infiltration. Dark and irregular cell nests with irregular cell architecture and little or no mucin were seen in submucosal carcinoma infiltration. Based on rates of correlation with pathological findings, the sensitivity, specificity, and accuracy of the classification of submucosal carcinoma infiltration by two observers were 91.7, 86.8, and 88.0 %, respectively. In addition, the results showed good interobserver agreement for the detection of submucosal carcinoma infiltration (κ = 0.757, standard error = 0.102). No adverse events occurred during the procedures. CONCLUSIONS Submucosa assessment by pCLE is feasible and safe. pCLE is useful for the differentiation of normal submucosa from carcinoma infiltration, particularly when infiltration is accompanied by severe fibrosis. Large-scale prospective studies are needed to further evaluate the clinical impact of the use of pCLE during endoscopy.
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Affiliation(s)
- Bun Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea.,Department of Medicine, The Graduate School, Yonsei University College of Medicine, Seoul, Korea.,Center for Colon Cancer, Center for Cancer Prevention and Detection, National Cancer Center, Goyang, Korea
| | - Yon Hee Kim
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Tae Il Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Won Ho Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Hoguen Kim
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Pil Hong
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea.
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Large Colorectal Lesions: Evaluation and Management. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 23:197-207. [PMID: 28868460 PMCID: PMC5580011 DOI: 10.1016/j.jpge.2016.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 01/04/2016] [Indexed: 02/07/2023]
Abstract
In the last years, a distinctive interest has been raised on large polypoid and non-polypoid colorectal tumors, and specially on flat neoplastic lesions ≥20 mm tending to grow laterally, the so called laterally spreading tumors (LST). Real or virtual chromoendoscopy, endoscopic ultrasound or magnetic resonance should be considered for the estimation of submucosal invasion of these neoplasms. Lesions suitable for endoscopic resection are those confined to the mucosa or selected cases with submucosal invasion ≤1000 μm. Polypectomy or endoscopic mucosal resection remain a first-line therapy for large colorectal neoplasms, whereas endoscopic submucosal dissection in high-volume centers or surgery should be considered for large LSTs for which en bloc resection is mandatory.
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Zhang QS, Han B, Xu JH, Gao P, Shen YC. Antimicrobial prophylaxis in patients with colorectal lesions undergoing endoscopic resection. World J Gastroenterol 2015; 21:4715-4721. [PMID: 25914483 PMCID: PMC4402321 DOI: 10.3748/wjg.v21.i15.4715] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 11/25/2014] [Accepted: 01/21/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the effect of prophylaxis with antibiotics on clinical adverse events in patients who underwent endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) for colorectal lesions.
METHODS: From June 2011 to December 2013, a total of 428 patients were enrolled into the study, of which 214 patients admitted to hospital underwent EMR or ESD procedures. These patients were randomized to an antibiotic group, in which patients were given cefuroxime 1.5 g iv half an hour before and 6 h after surgery respectively, and a control group, in which patients were not given any antibiotic. A further 214 outpatients with small polyps treated by polypectomy were compared with controls that were matched by age and gender, and operations were performed as outpatient surgery. Recorded patient parameters were demographics, characteristics of lesions and treatment modality, and the size of the wound area. The primary outcome measures were clinical adverse events, including abdominal pain, diarrhea, hemotachezia, and fever. Secondary outcome measures were white blood cell count, C-reactive protein and blood culture. Additionlly, the relationship between the size of the wound area and clinical adverse events was analyzed.
RESULTS: A total of 409 patients were enrolled in this study, with 107 patients in the control group, 107 patients in the antibiotic group, and another 195 cases in the follow-up outpatient group. The patients’ demographic characteristics, including age, gender, characteristics of lesions, treatment modality, and the size of the wound area were similar between the 2 groups. The rates of adverse events in the antibiotic group were significantly lower than in the control group: abdominal pain (2.8% vs 14.9%, P < 0.01), diarrhea (2.0% vs 9.3%, P < 0.05), and fever (0.9% vs 8.4%, P < 0.05) respectively. The levels of inflammatory markers also decreased significantly in the antibiotic group compared with the control group: leukocytosis (2.0% vs 11.2%, P < 0.01), and C-reactive protein (2.0% vs 10.7%, P < 0.05). Additionally, clinical adverse events were related to the size of the surgical wound area. When the surgical wound area was larger than 10 mm × 10 mm, there were more clinical adverse events.
CONCLUSION: Clinical adverse events are not uncommon after EMR or ESD procedures. Prophylactic antibiotics can reduce the incidence of clinical adverse events. This should be further explored.
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Abstract
Although removal of adenomatous polyps has been shown to decrease the risk of colon cancer, distal hyperplastic polyps are thought to not have malignant potential. Most polyps detected during colonoscopy are diminutive (≤ 5 mm) and rarely harbor advanced histology, such as high-grade dysplasia or cancer. Therefore, predicting histology in real-time during colonoscopy can potentially decrease the enormous expenditure that ensues from universal histopathologic evaluation of polyps, and several novel imaging technologies have been developed and tested over the past decade for this purpose. Of these different technologies, electronic chromoendoscopy seems to strike a fair balance between accuracy, feasibility, and cost.
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Affiliation(s)
- Shreyas Saligram
- University of Kansas School of Medicine, University of Kansas, Department of Gastroenterology, 3901 Rainbow Blvd, Kansas City, KS 66160, USA; Veterans Affairs Medical Center, Department of Gastroenterology, 4801 Linwood Blvd, Kansas City, MO 64128, USA
| | - Amit Rastogi
- University of Kansas School of Medicine, University of Kansas, Department of Gastroenterology, 3901 Rainbow Blvd, Kansas City, KS 66160, USA; Veterans Affairs Medical Center, Department of Gastroenterology, 4801 Linwood Blvd, Kansas City, MO 64128, USA.
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Abstract
Although often viewed as a single disease, colorectal cancer more accurately represents a family of diseases with different precursor lesions. Conventional (tubular, tubulovillous and villous) adenomas are the most common neoplastic lesions occurring in the large intestine. They have adenomatous polyposis coli (APC) mutations and arise from dysplastic aberrant crypt foci, initially as polyclonal lesions. In sporadic tumours, neoplastic progression follows the traditional pathway (chromosomal instability pathway), resulting in CpG island methylator phenotype (CIMP)-negative, microsatellite-stable (MSS), BRAF and KRAS wild-type cancers. Germline mutations in the APC gene lead to familial adenomatous polyposis. Conventional adenomas are also the precursors of Lynch syndrome-associated microsatellite-instable (MSI-high) cancers. Sessile serrated adenoma/polyp (SSA/P) is the principal precursor lesion of the serrated pathway, in which BRAF mutation can lead to colorectal cancer with MSI-high CIMP-high or MSS CIMP-high phenotype. SSA/Ps have been associated with synchronous and metachronous invasive adenocarcinomas as well as so-called interval carcinomas. Serrated polyposis is rare but most likely underdiagnosed. Affected individuals bear an increased but unspecified risk for the development of colorectal cancer; close endoscopic surveillance is warranted. Traditional serrated adenomas (TSAs) are much less common than the other serrated lesions. Cancers originating from TSAs may show KRAS mutation with a CIMP-high MSS phenotype.
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Affiliation(s)
- Cord Langner
- Institute of Pathology, Medical University of Graz, Graz, Austria
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Limketkai BN, Lam-Himlin D, Arnold MA, Arnold CA. The cutting edge of serrated polyps: a practical guide to approaching and managing serrated colon polyps. Gastrointest Endosc 2013; 77:360-75. [PMID: 23410696 DOI: 10.1016/j.gie.2012.11.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 11/06/2012] [Indexed: 12/13/2022]
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16
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Xu JC, Liu BR. Endoscopic techniques for improving colorectal adenoma detection: Recent progress. Shijie Huaren Xiaohua Zazhi 2012; 20:3118-3123. [DOI: 10.11569/wcjd.v20.i32.3118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) is one of the most common malignant neoplasms worldwide and develops mostly from precancerous lesions such as colorectal adenomas. Therefore, early detection and resection of colorectal adenomas is key to preventing CRC. At present, colonoscopy is acknowledged as the gold standard for the diagnosis and treatment of colorectal lesions; however, conventional colonoscopy is still associated with a certain rate of missed lesions. It is reported that the missed detection rate is 6% when adenomas are more than 1 cm, 13% for adenomas 6-9 mm, and 27% for adenomas less than 5 mm. The missed detection rate for right colonic adenomas is higher than that for left colonic adenomas. The missed diagnosis of colorectal adenomas or malignant tumors invariably increases surgical rate and mortality. Currently, great efforts have been made to improve the detection rate of colorectal adenomas. This paper will briefly review recent advances in endoscopic techniques for improving the detection rate of colorectal adenomas.
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Ng SC, Tsoi KKF, Hirai HW, Lee YT, Wu JCY, Sung JJY, Chan FKL, Lau JYW. The efficacy of cap-assisted colonoscopy in polyp detection and cecal intubation: a meta-analysis of randomized controlled trials. Am J Gastroenterol 2012; 107:1165-73. [PMID: 22664471 DOI: 10.1038/ajg.2012.135] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The role of cap-assisted colonoscopy (CAC) in polyp detection and cecal intubation is unclear. We conducted a meta-analysis to compare the efficacy of CAC vs. standard colonoscopy (SC). METHODS Publications in English and non-English literatures (OVID, MEDLINE, and EMBASE) and abstracts in major international conferences were searched for controlled trials comparing CAC and SC. Outcome measures included the proportion of patients with polyps or adenomas detected, cecal intubation rate, cecal intubation time, and total colonoscopy time. The statistical heterogeneity of trials was examined and the effects were pooled by random-effects model. The risk of bias was evaluated by the assessment tool from the Cochrane Handbook. Subgroup analyses were performed for possible clinical and methodological heterogeneities. RESULTS From 2,358 citations, 16 randomized controlled clinical trials were included consisting of 8,991 subjects (CAC: 4,501; SC: 4,490). Mean age of subjects was 61.0 years old and 60% were males. CAC detected a higher proportion of patients with polyp(s) (relative risk (RR): 1.08; 95% confidence interval (CI): 1.00-1.17) and reduced the cecal intubation time (mean difference: -0.64 min; 95% CI: -1.19 to -0.10). Cecal intubation rate (RR: 1.00; 95% CI: 0.99-1.02) and total colonoscopy time (mean difference: -0.97 min; 95% CI: -2.33 to 0.40) were comparable between the two groups. In subgroup analyses, a short cap (≤4 mm) was associated with improved polyp detection, whereas a long cap (≥7 mm) was associated with a shorter cecal intubation time. CONCLUSIONS CAC demonstrated marginal benefit over SC for polyp detection and shortened the cecal intubation time.
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Affiliation(s)
- Siew C Ng
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong.
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18
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Abstract
Rectal cancer is a distinct subset of colorectal cancer where specialized disease-specific management of the primary tumor is required. There have been significant developments in rectal cancer surgery at all stages of disease in particular the introduction of local excision strategies for preinvasive and early cancers, standardized total mesorectal excision for resectable cancers incorporating preoperative short- or long-course chemoradiation to the multimodality sequencing of treatment. Laparoscopic surgery is also increasingly being adopted as the standard rectal cancer surgery approach following expertise of colorectal surgeons in minimally invasive surgery gained from laparoscopic colon resections. In locally advanced and metastatic disease, combining chemoradiation with radical surgery may achieve total eradication of disease and disease control in the pelvis. Evidence for resection of metastases to the liver and lung have been extensively reported in the literature. The role of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal metastases is showing promise in achieving locoregional control of peritoneal dissemination. This paper summarizes the recent developments in approaches to rectal cancer surgery at all these time points of the disease natural history.
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Raju GS, Saito Y, Matsuda T, Kaltenbach T, Soetikno R. Endoscopic management of colonoscopic perforations (with videos). Gastrointest Endosc 2011; 74:1380-8. [PMID: 22136781 DOI: 10.1016/j.gie.2011.08.007] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 08/04/2011] [Indexed: 02/08/2023]
Affiliation(s)
- Gottumukkala S Raju
- Department of Gastroenterology, Hepatology, and Nutrition, University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
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Santos CEOD, Malaman D, Pereira-Lima JC. Endoscopic mucosal resection in colorectal lesion: a safe and effective procedure even in lesions larger than 2 cm and in carcinomas. ARQUIVOS DE GASTROENTEROLOGIA 2011; 48:242-7. [DOI: 10.1590/s0004-28032011000400005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 07/14/2011] [Indexed: 02/07/2023]
Abstract
CONTEXT: Endoscopic mucosal resection is a minimally invasive technique used in the treatment of colorectal neoplasms, including early carcinomas of different size and morphology. OBJECTIVES: To evaluate procedure safety, efficacy, outcomes, and recurrence rate in endoscopic mucosal resection of colorectal lesions. METHODS: A total of 172 lesions in 156 patients were analyzed between May 2003 and May 2009. All lesions showed pit pattern suggestive of neoplasia (Kudo types III-V) at high-magnification chromocolonoscopy with indigo carmine. The lesions were evaluated for macroscopic classification, size, location, and histopathology. Lesions 20 mm or smaller were resected en bloc and lesions larger than 20 mm were removed using the piecemeal technique. Complications and recurrence were analyzed. Patients were followed up for 18 months. RESULTS: There were 83 (48.2%) superficial lesions, 57 (33.1%) depressed lesions, 44 (25.6%) laterally spreading tumors, and 45 (26.2%) protruding lesions. Mean lesion size was 11.5 mm ± 9.6 mm (2 mm-60 mm). Patients' mean age was 61.6 ± 12.5 years (34-93 years). Regarding lesion site, 24 (14.0%) lesions were located in the rectum, 68 (39.5%) in the left colon, and 80 (46.5%) in the right colon (transverse, ascending, and cecum). There were 167 (97.1%) neoplasms: 142 (82.5%) adenomatous lesions, 24 (14.0%) intramucosal carcinomas, and 1 (0.6%) invasive carcinoma. En bloc resection was performed in 158 (91.9%) cases and piecemeal resection in 14 (8.1%). Bleeding occurred in 5 (2.9%) cases. Recurrence was observed in 4.1% (5/122) of cases and was associated with lesions larger than 20 mm (P<0.01), piecemeal resection (P<0.01), advanced neoplasm (P = 0.01), and carcinoma compared to adenoma (P = 0.04). CONCLUSIONS: Endoscopic mucosal resection of colorectal lesions is a safe and effective procedure, with low complication and local recurrence rates. Recurrence is associated with lesions larger than 20 mm and carcinomas.
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22
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Langner C. [Non-serrated precursor lesions of colorectal tumours]. DER PATHOLOGE 2011; 32 Suppl 2:206-10. [PMID: 21845358 DOI: 10.1007/s00292-011-1495-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Non-serrated precursor lesions of colorectal tumours include conventional adenomas (tubular, tubulovillous and villous), inflammatory bowel disease-associated dysplasia (intraepithelial neoplasia), and hamartoma-associated dysplasia. This short review summarizes the current literature on the adenoma-carcinoma sequence, focusing on colonic stem cells and functional crypt organization, patterns of stem cell division, niche succession and clonal conversion in the formation of a monocryptal adenoma. The process of clonal interaction between neighboring crypts as well as the development of large monoclonal adenomas from small polyclonal precursor lesions is discussed in detail. Finally, the molecular pathogenesis as well as the clinical significance of inflammatory bowel disease- and hamartoma-associated carcinogenesis is addressed.
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Affiliation(s)
- C Langner
- Institut für Pathologie, Medizinische Universität Graz, Auenbruggerplatz 25, 8036, Graz, Österreich.
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23
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Chiapponi C, Stocker U, Körner M, Ladurner R. Emergency percutaneous needle decompression for tension pneumoperitoneum. BMC Gastroenterol 2011; 11:48. [PMID: 21545727 PMCID: PMC3112115 DOI: 10.1186/1471-230x-11-48] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Accepted: 05/05/2011] [Indexed: 12/28/2022] Open
Abstract
Background Tension pneumoperitoneum as a complication of iatrogenic bowel perforation during endoscopy is a dramatic condition in which intraperitoneal air under pressure causes hemodynamic and ventilatory compromise. Like tension pneumothorax, urgent intervention is required. Immediate surgical decompression though is not always possible due to the limitations of the preclinical management and sometimes to capacity constraints of medical staff and equipment in the clinic. Methods This is a retrospective analysis of cases of pneumoperitoneum and tension pneumoperitoneum due to iatrogenic bowel perforation. All patients admitted to our surgical department between January 2005 and October 2010 were included. Tension pneumoperitoneum was diagnosed in those patients presenting signs of hemodynamic and ventilatory compromise in addition to abdominal distension. Results Between January 2005 and October 2010 eleven patients with iatrogenic bowel perforation were admitted to our surgical department. The mean time between perforation and admission was 36 ± 14 hrs (range 30 min - 130 hrs), between ER admission and begin of the operation 3 hrs and 15 min ± 47 min (range 60 min - 9 hrs). Three out of eleven patients had clinical signs of tension pneumoperitoneum. In those patients emergency percutaneous needle decompression was performed with a 16G venous catheter. This improved significantly the patients' condition (stabilization of vital signs, reducing jugular vein congestion), bridging the time to the start of the operation. Conclusions Hemodynamical and respiratory compromise in addition to abdominal distension shortly after endoscopy are strongly suggestive of tension pneumoperitoneum due to iatrogenic bowel perforation. This is a rare but life threatening condition and it can be managed in a preclinical and clinical setting with emergency percutaneous needle decompression like tension pneumothorax. Emergency percutaneous decompression is no definitive treatment, only a method to bridge the time gap to definitive surgical repair.
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Affiliation(s)
- Costanza Chiapponi
- Department of Surgery, Hospital of the Ludwig-Maximilians-University, Nussbaumstr, 20, 80336 Munich, Germany.
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Othman MO, Wallace MB. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) in 2011, a Western perspective. Clin Res Hepatol Gastroenterol 2011; 35:288-94. [PMID: 21458402 DOI: 10.1016/j.clinre.2011.02.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Accepted: 02/09/2011] [Indexed: 02/06/2023]
Abstract
Endoscopic mucosal resection (EMR) has become the standard of care for removal of large flat and sessile neoplastic lesions of the GI tract. Recently, endoscopic submucosal dissection (ESD) was introduced in Japan as an alternative technique, which allows en bloc resection of large lesions. The applications of EMR and ESD are expanding and many Western endoscopists are adopting these techniques. Paris classification and Kudo pit pattern classification allows prediction of the depth of invasion of early neoplastic lesions and thus, avoids resection of lesions invading the deep submucosa which have higher rates of lymphatic spread. ESD of early stomach cancer is the standard of care in Japan. Recent published reports from Western countries showed comparable results for ESD of early gastric cancers to those done in Japan. Recently, EMR combined with ablation has been used frequently in Western countries for treatment of high-grade dysplasia in early adenocarcinoma of the esophagus. Although ESD of early neoplastic lesions of the esophagus is technically difficult, few promising reports were published proving the feasibility of this technique in the West. ESD has been shown to achieve higher en bloc resection and lower rates of tumour recurrence in removal of lateral spreading colonic polyps. A hybrid technique of circumferential submucosal incision followed by en bloc EMR has been used for removal of large colonic lesions in some Western endoscopy centres. In Western countries, training for ESD is challenging given the lack of training in the relatively easier early gastric cancer lesions. Animal model training combined with observing experts in ESD could be an alternative for Western endoscopists. Inspite of obstacles, ESD applications are continuing to grow in Western countries.
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Affiliation(s)
- Mohamed O Othman
- Division of gastroenterology and hepatology, Mayo Clinic, 4500, San Pablo Road, 32224 Jacksonville, United States
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Ikehara H, Saito Y, Matsuda T, Uraoka T, Murakami Y. Diagnosis of depth of invasion for early colorectal cancer using magnifying colonoscopy. J Gastroenterol Hepatol 2010; 25:905-12. [PMID: 20546444 DOI: 10.1111/j.1440-1746.2010.06275.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Early colorectal cancer (CRC) with submucosal deep (s.m.-d.) invasion should not be treated with endoscopic mucosal resection due to the higher incidence of lymph-node metastasis. It is, therefore, clinically important to accurately diagnose s.m.-d. lesions before treatment. METHODS We analyzed the endoscopic features, including pit patterns, of early CRC with s.m.-d. invasion observed using magnifying colonoscopy. We retrospectively investigated 379 cases of early CRC. Lesions were divided into three macroscopic subtypes (pedunculated type, sessile type and superficial type) based on endoscopic findings. Eight endoscopic factors were evaluated retrospectively for association with s.m. invasion and then compared to histopathological findings. RESULTS The superficial type had a significantly higher frequency of s.m.-d. invasion (52.4% [77/147] vs 24.6% [14/57] and 39.4% [69/175], P-value < 0.05, respectively, for pedunculated and sessile types). Based on multivariate analysis, an independent risk factor for s.m.-d. invasion was the existence of an invasive pit pattern in sessile and superficial types (odds ratios of 52.74 and 209.67, respectively). Fullness was also an independent risk factor for s.m.-d. invasion in the superficial type (odds ratio = 9.25). There were no independent risk factors for s.m.-d. invasion in the pedunculated type. CONCLUSION High magnification pit pattern diagnosis proved to be useful for predicting s.m.-d. invasion in sessile and superficial types although it was not as helpful with the pedunculated type.
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Affiliation(s)
- Hisatomo Ikehara
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
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Abstract
This review discusses the incidence, risk factors, management and outcome of colonoscopic perforation (CP). The incidence of CP ranges from 0.016% to 0.2% following diagnostic colonoscopies and could be up to 5% following some colonoscopic interventions. The perforations are frequently related to therapeutic colonoscopies and are associated with patients of advanced age or with multiple comorbidities. Management of CP is mainly based on patients’ clinical grounds and their underlying colorectal diseases. Current therapeutic approaches include conservative management (bowel rest plus the administration of broad-spectrum antibiotics), endoscopic management, and operative management (open or laparoscopic approach). The applications of each treatment are discussed. Overall outcomes of patients with CP are also addressed.
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Li X, Chen H, Gao Y, Chen X, Ge Z. Prediction of histology and invasive depth of colorectal neoplasia based on morphology of surface depression using magnifying chromocolonoscopy. Int J Colorectal Dis 2010; 25:79-85. [PMID: 19859721 DOI: 10.1007/s00384-009-0821-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2009] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND STUDY AIMS Estimation of histology and depth of invasion in early colorectal neoplasia is essential for patient treatment. We therefore conducted a prospective study to examine whether the morphology of depression area contained at the surface of colorectal neoplasia can be used for predicting the histology and invasive depth. METHODS A series of 228 consecutive patients with 296 colorectal lesions were studied. All lesions were evaluated by magnifying chromocolonoscopy. Surface depression contained in the lesions was noted and the depressive morphology was further divided into two subgroups of type I and type II. All of the lesions were resected endoscopically or surgically and examined histologically for comparison. RESULTS A total of 296 lesions were evaluated, of which 66 (22.3%) contained an area of central depression, including 43 in nonpolypoid (flat and depressed) lesions (66%) and 23 in polypoid (10%). The overall accuracy of depressive morphology for distinction between low-grade dysplasia and high-grade dysplasia/invasive cancer, and between m-sm1 and sm2-sm3 was 86.4% and 84.8%, respectively. CONCLUSIONS Depression was predominantly contained in nonpolypoid colorectal neoplasia. Morphology of depression observed by magnifying chromocolonoscopy could be used as a complementary method to assess the degree of atypia and invasive depth in colorectal neoplasia.
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Affiliation(s)
- Xiaobo Li
- Department of Gastroenterology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Institute of Digestive Disease, China
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Legoux JL, Ntagirabiri R, Belleannée G, Sauvé G, Boulogne S, Couzigou P. Structural enhancement and video endoscopy: results of a large prospective comparative study. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2009; 33:1101-1105. [PMID: 19864101 DOI: 10.1016/j.gcb.2009.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2009] [Revised: 06/19/2009] [Accepted: 06/20/2009] [Indexed: 05/28/2023]
Abstract
INTRODUCTION The structural-enhancement (SE) function electronically improves the video-endoscopic signal of Olympus processors (EXERA CV-160 or greater), enabling an increase in relief that may help in the detection of flat or ulcerated and raised lesions, especially those of small size. We assessed the diagnostic impact of this technique in the screening of lesions during basic video colonoscopy. METHODS Maximum-level SE was programmed into processors on alternate weeks, and endoscopy dates were planned by an assistant unaware of the SE schedule, thus ensuring randomization. The endoscopists-senior practitioners with 3-29 years of digestive endoscopy practice-were informed of the experiment >3 weeks before it began and were not told about it again either before or during the study. This was to ensure that endoscopy examinations were performed without over-awareness of the technical conditions. GIF-100 to -160 Olympus endoscopes were used. RESULTS During the study, 606 patients underwent upper digestive video-endoscopy, 305 with and 301 without the use of the SE function. Of 645 patients who underwent video colonoscopy, 593 were included in the study and 52 were excluded due to poor cleansing (8%); of those included, 330 were analyzed with and 263 without the SE function. We observed no differences in the detection of lesions (small or large) by either upper digestive endoscopy or video colonoscopy. CONCLUSION This is the first study comparing video-endoscopy diagnosis with or without SE during upper digestive endoscopy and colonoscopy. The SE function available on Olympus video-endoscopy processors had no impact on the detection of lesions, not even on those of very small size.
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Affiliation(s)
- J-L Legoux
- Hepato-Gastroenterology Department, La-Source Hospital, Orleans Regional Hospital, Orleans cedex 2, France.
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Lymphatic vessel invasion detected by monoclonal antibody D2-40 as a predictor of lymph node metastasis in T1 colorectal cancer. Int J Colorectal Dis 2009; 24:1069-74. [PMID: 19387662 DOI: 10.1007/s00384-009-0699-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2009] [Indexed: 02/04/2023]
Abstract
OBJECTIVE When selecting patients who are at high risk for lymph node metastasis, the detection of lymphatic vessel invasion (LVI) is important. We investigated LVI detected by D2-40 staining as a predictor of lymph node metastasis in T1 colorectal cancer. MATERIALS AND METHODS Clinicopathological factors including LVI were investigated in 136 patients who underwent colectomy with lymph node dissection for T1 colorectal cancer. We used immunostaining with monoclonal antibody D2-40 to detect LVI. RESULTS Lymph node metastases were found in 18 patients (13.2%), and LVI were detected in 45 (33%); lymph node metastasis was more frequently observed in LVI-positive groups (13/45 vs 5/91, p < 0.001). Both univariate and multivariate analyses revealed that LVI detected by D2-40 and a poorly differentiated histology at the invasion front were independent risk factors of lymph node metastasis. CONCLUSION LVI detected by D2-40 is important for the prediction of lymph node metastasis.
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Mönkemüller K, Neumann H, Malfertheiner P, Fry LC. Advanced colon polypectomy. Clin Gastroenterol Hepatol 2009; 7:641-52. [PMID: 19281865 DOI: 10.1016/j.cgh.2009.02.032] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Revised: 02/16/2009] [Accepted: 02/21/2009] [Indexed: 02/07/2023]
Affiliation(s)
- Klaus Mönkemüller
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Leipziger Strasse 44, Magdeburg 39120, Germany.
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Hurlstone DP, Shorthouse AJ, Brown SR, Tiffin N, Cross SS. Salvage endoscopic submucosal dissection for residual or local recurrent intraepithelial neoplasia in the colorectum: a prospective analysis. Colorectal Dis 2008; 10:891-7. [PMID: 18355372 DOI: 10.1111/j.1463-1318.2008.01510.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE A prospective technical feasibility study of cap assisted ESD for 'curative intent' in patients with residual or local neoplastic recurrence following EMR. Primary end points were second stage R0 resection rate, safety and recurrence. METHOD Salvage ESD was performed using the Olympus GIF-XQ240 gastroscope and KD-630L insulation tipped knife. Thirty-day mortality, re-admission rates, complications and histological resection status were collected prospectively up to 9 months following index resection. RESULTS Thirty patients met eligibility criteria. Index R0 resection was achieved in 25/30 (83%) lesions. One patient underwent surgical excision with a second receiving a curative second stage dissection. Ninety-six per cent (29/30) patients were discharged within 24 h of the procedure with a 0% 30-day mortality and re-admission rate. Bleeding occurred in 5/30 (16%) treated successfully with endoluminal haemostasis. There were no perforations. Overall 'cure' rates at short-term follow-up [median 6/12 (range; 3-18)] was 96%. CONCLUSION This novel application of ESD for first line 'salvage' therapy in treating residual or locally recurrent neoplastic disease may be a safe, minimally invasive and cost effective alternative to direct surgical resection in a select patient cohort.
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Affiliation(s)
- D P Hurlstone
- Gastroenterology and Liver Unit at the Royal Hallamshire Hospital, Sheffield, UK.
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Hurlstone DP. The detection of flat and depressed colorectal lesions: which endoscopic imaging approach? Gastroenterology 2008; 135:338-43. [PMID: 18621048 DOI: 10.1053/j.gastro.2008.06.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- David P Hurlstone
- Royal Hallamshire Hospital, Department of Endoscopy, University of Sheffield, South Yorkshire, United Kingdom.
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Min BH, Chang DK, Kim DU, Kim YH, Rhee PL, Kim JJ, Rhee JC. Low frequency of bacteremia after an endoscopic resection for large colorectal tumors in spite of extensive submucosal exposure. Gastrointest Endosc 2008; 68:105-10. [PMID: 18402955 DOI: 10.1016/j.gie.2007.11.051] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2007] [Accepted: 11/24/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND During an EMR or endoscopic submucosal dissection (ESD) for colorectal tumors, an injection needle catheter is passed through the contaminated endoscopic channel and may directly inoculate bacteria into the blood stream during submucosal injection. In addition, extensively exposed submucosa, especially with an ESD, directly contacts colonic luminal bacteria after the procedure, which may increase the risk of bacteremia. However, the incidence of bacteremia after an EMR or ESD for colorectal tumors has not been reported. OBJECTIVE To evaluate the frequency of bacteremia associated with an EMR or ESD for colon lesions. DESIGN A prospective study. PATIENTS A total of 40 patients who underwent a conventional EMR (n = 30), an EMR after circumferential pre-cutting (n = 3), or ESD (n = 7) for colorectal tumors. INTERVENTIONS AND MAIN OUTCOME MEASUREMENTS Blood cultures were obtained immediately before, 5 minutes after, and 30 minutes after the procedure. Patients were closely monitored for 24 hours after the procedure to detect the development of infectious complications. RESULTS Blood cultures at baseline and 5 minutes after the procedure were all negative. However, a blood culture at 30 minutes after the procedure showed a positive result in 1 of 40 patients (2.5%). This patient underwent a conventional EMR, and the isolated microorganism was coagulase-negative Staphylococcus, which might be regarded as a contaminant. None of the 40 patients showed any signs or symptoms associated with infection. LIMITATION The small sample size. CONCLUSIONS An EMR, or even an ESD, for colon lesions may be considered a low-risk procedure for infectious complications that does not warrant prophylactic administration of antibiotics.
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Affiliation(s)
- Byung-Hoon Min
- Department of Medicine, Sungkyunkwan University School of Medicine, Samsung Medical Center, Gangnam-gu, Seoul, Korea
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Smith LA, Tiffin N, Thomson M, Cross SS, Hurlstone DP. Chromoscopic endomicroscopy: in vivo cellular resolution imaging of the colorectum. J Gastroenterol Hepatol 2008; 23:1009-23. [PMID: 18557799 DOI: 10.1111/j.1440-1746.2008.05463.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Advances in imaging technology and engineering have now permitted functional integration of a confocal endomicroscope into the distal tip of a conventional video colonoscope enabling imaging of the surface epithelium and the underlying lamina propria during ongoing video endoscopy. For the first time, the endoscopist is now able to resolve the surface and subsurface mucosa at cellular resolution in vivo and in real time. A new era in endoscopic imaging has therefore begun - histoendoscopy. In addition to providing a high-accuracy in vivo optical biopsy tool for the differentiation between benign hyperplasia, intra-epithelial neoplasia and carcinoma in sporadic cohorts, endomicroscopy with targeted biopsies has now been shown to increase the yield of intra-epithelial neoplasia complicating ulcerative colitis. Furthermore, recent data examining endomicroscopic molecular ex vivo imaging using anti-CD44v6 antibody has identified aberrant crypt foci based on their surface molecular expression. Receptor overexpression in vivo in humans may, in the near future, be exploited for the diagnosis of inflammation, neoplasia and in predicting targeted molecular therapy. Endomicroscopy will be key to this immuno-imaging interface. Within the present review, we discuss the current clinical evidence in support of confocal endomicroscopy and explore the new diagnostic possibilities for this technology.
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Godeberge P, Blain A, Christidis C, Mal F. [Medical-surgical decision-making for the treatment of polypoid lesions of the colon]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2008; 32:S152-S157. [PMID: 18479859 DOI: 10.1016/j.gcb.2008.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- P Godeberge
- Département médico-chirurgical de pathologie digestive, institut mutualiste Montsouris, université Paris-5, 42, boulevard Jourdan, 75014 Paris, France.
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Poppers DM, Haber GB. Endoscopic mucosal resection of colonic lesions: current applications and future prospects. Med Clin North Am 2008; 92:687-705, x. [PMID: 18387382 DOI: 10.1016/j.mcna.2008.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The introduction of submucosal fluid injection has remarkably extended the range of endoscopically resectable polyps. The limiting factor for endoscopic resection is not polyp size, but polyp depth. Endoscopic ultrasound is a useful adjunctive diagnostic tool to assess the depth of invasion. The success of are section ultimately depends on pathologic confirmation of a benign nature of this lesion or of a cancer limited to the mucosa. Selected well-differentiated cancers without lymphovascular invasion of the superficial submucosa can be successfully resected endoscopically.
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Affiliation(s)
- David M Poppers
- Division of Gastroenterology, Center for Advanced Therapeutic Endoscopy, Lenox Hill Hospital, 6 Black Hall, 100 East 77th Street, New York, NY 10021, USA
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Hurlstone DP, Atkinson R, Sanders DS, Thomson M, Cross SS, Brown S. Achieving R0 resection in the colorectum using endoscopic submucosal dissection. Br J Surg 2007; 94:1536-42. [PMID: 17948864 DOI: 10.1002/bjs.5720] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic mucosal resection is established for the removal of non-invasive colorectal tumours smaller than 20 mm but is unsatisfactory for larger lesions. Endoscopic submucosal dissection (ESD) enables en bloc resection of lesions larger than 20 mm. A UK-based prospective feasibility study of ESD for colorectal tumours was undertaken; primary endpoints were R0 resection, safety and recurrence. METHODS Patients with Paris 0-II adenomas or laterally spreading tumours (LSTs) greater than 20 mm in diameter were enrolled between November 2004 and August 2006. Lesions were assessed by chromoscopy and high-frequency ultrasonography. Dysplasia, resection status, 30-day complication rates and recurrence after ESD were recorded. RESULTS ESD was performed in 42 of 56 identified patients; en bloc resection was possible in 33. Fourteen Paris 0-II lesions and 28 LSTs were identified; 40 were dysplastic adenomas and two adenocarcinomas. R0 resection was achieved in 31 patients (74 per cent). The 30-day mortality rate was 0 per cent. Perforation occurred in one patient and uncomplicated bleeding in five. The 6-month cure rate was 81 per cent (34 of 42 patients). CONCLUSION High cure rates are achievable using ESD for Paris 0-II adenomas and LSTs greater than 20 mm in diameter, with R0 resection possible in most patients. ESD is feasible throughout the colorectum with no increase in complication rates. It should be considered for selected Tim/T1 N0 colorectal lesions.
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Affiliation(s)
- D P Hurlstone
- Gastroenterology and Liver Unit, Royal Hallamshire Hospital, Sheffield, UK.
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40
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Zanoni ECA, Cutait R, Averbach M, de Oliveira LAR, Teixeira CR, Corrêa PAFP, Paccos JL, Rossini GF, Câmara Lopes LH. Magnifying colonoscopy: interobserver agreement in the assessment of colonic pit patterns and its correlation with histopathological findings. Int J Colorectal Dis 2007; 22:1383-8. [PMID: 17579873 DOI: 10.1007/s00384-007-0336-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND STUDY AIMS Magnifying colonoscopy (MC) is recognized as an aid to the differential diagnosis between neoplastic and nonneoplastic lesions. This study evaluated interobserver agreement of experienced endoscopists in the assessment of colonic pit patterns through the Kudo's classification and correlated morphological aspects with histopathological findings. MATERIALS AND METHODS A total of 213 magnification chromoendoscopic pictures of colonic lesions were collected from 161 consecutive patients and presented to three independent observers who expressed opinion about predominant pit pattern. All lesions were excised and sent for histopathological study. RESULTS Kappa statistics showed that the general agreement index with respect to the aspects of the pits was good among the three observers (0.561). Regarding prediction of histopathology according to the pit pattern diagnosis, overall accuracy was 84%, sensitivity was 91.4%, specificity was 67.2%, positive predictive value was 86.6%, and negative predictive value was 79.3%. CONCLUSION Although the interobserver reproducibility of the colonic pit pattern is good for experienced endoscopists, MC must not be used to replace the histopathological analysis, since it does not differentiate with the necessary safety neoplastic from nonneoplastic lesions.
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Hurlstone DP, Thomson M, Brown S, Tiffin N, Cross SS, Hunter MD. Confocal endomicroscopy in ulcerative colitis: differentiating dysplasia-associated lesional mass and adenoma-like mass. Clin Gastroenterol Hepatol 2007; 5:1235-41. [PMID: 17690019 DOI: 10.1016/j.cgh.2007.06.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS The management of dysplasia-associated lesional mass (DALM) and adenoma-like mass (ALM) in chronic ulcerative colitis (CUC) differs radically, involving total pan-proctocolectomy vs endoscopic resection and surveillance. Such lesions cannot be reliably differentiated using conventional colonoscopy. Confocal laser scanning imaging enables in vivo surface and subsurface cellular resolution imaging during ongoing video endoscopy. The aim of this study was to prospectively assess the clinical applicability and predictive power of the Pentax EC3870K endomicroscope for the in vivo differentiation of ALM and DALM in CUC during ongoing videocolonoscopy. METHODS Patients were recruited who had a diagnosis of ALM or DALM within the previous 16 weeks. Confocal laser endomicroscopic (CLE) imaging of the circumscribed lesion and 4 adjacent mucosal segments was performed. Targeted biopsy with and without tissue sampling with endoscopic mucosal resection was performed and compared with conventional histopathology as the gold standard. RESULTS Thirty-six patients with 36 lesions fulfilled the study entry criteria. Using modified Mainz criteria for the in vivo diagnosis of ALM and DALM, the kappa coefficient of agreement between CLE and histopathologic evaluation was 0.91, and accuracy was 97% (95% confidence interval = 86%-99%). CONCLUSIONS This is the first study addressing the novel application of the Pentax EC3870K endomicroscopy system for the in vivo differentiation of ALM and DALM during ongoing video colonoscopy in CUC. We have shown that ALM and DALM can be differentiated with a high overall accuracy, enabling the safe selection of patients suitable for endoluminal resection versus immediate referral for pan-proctocolectomy.
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Affiliation(s)
- David P Hurlstone
- Gastroenterology and Liver Unit, Royal Hallamshire Hospital, Sheffield, UK
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Hurlstone DP, George R, Brown S. Novel clinical in vivo roles for indigo carmine: high-magnification chromoscopic colonoscopy. Biotech Histochem 2007; 82:57-71. [PMID: 17577700 DOI: 10.1080/10520290701259340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Since the adenoma-carcinoma sequence was first proposed by Morson in the 1970s, it has become widely accepted that detection and subsequent removal of polypoid adenomas from the colon reduces the incidence of colorectal cancer. These adenomas are relatively easy to detect by conventional colonoscopy; however, large population studies have shown that despite resection of polypoid adenomas, interval colorectal cancers still occurred. Recent advances in technology have given today's endoscopists access to high-resolution and high-magnification scopes, which has facilitated detection of flat and depressed colorectal lesions. Current data suggest that such morphologically distinct lesions may account for up to 30% of all colorectal adenomas. Furthermore, flat and depressed lesions of the large bowel may confer greater malignant potential compared to polypoid adenomas. The majority of flat lesions show only subtle changes by conventional colonoscopy, but the use of stains, such as indigocarmine, in addition to magnification colonoscopy can enhance their detection significantly. In this paper, we discuss the rationale for detecting flat colorectal lesions. We explore the use of high-magnification colonoscopy and chromoendoscopy, with particular reference to the application of indigocarmine, in this patient group. We also discuss the novel therapeutic techniques now available for these lesions.
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Affiliation(s)
- D P Hurlstone
- Gastroenterology and Liver Unit, Royal Hallamshire Hospital, Sheffield, UK.
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Picasso M, Filiberti R, Blanchi S, Conio M. The role of chromoendoscopy in the surveillance of the duodenum of patients with familial adenomatous polyposis. Dig Dis Sci 2007; 52:1906-9. [PMID: 17406831 DOI: 10.1007/s10620-006-9653-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2006] [Accepted: 10/15/2006] [Indexed: 12/16/2022]
Abstract
Adenomas of the duodenum have been described in patients with familial adenomatous polyposis (FAP). Patients with FAP are at high risk for the development of periampullary cancer. The aim of our study was to evaluate if endoscopic visualization of small polyps, often overlooked at standard endoscopic examination, was improved by chromoendoscopy. Ten patients with FAP and previous colectomy underwent upper gastrointestinal endoscopy. Two skilled endoscopists were involved for each endoscopy. Evaluation of number and diameter of polyps was made before and after staining. After staining we detected a larger number of duodenal polyps than found at the standard endoscopic examination, the difference being statistically significant. This result seems to suggest that chromoendoscopy may improve diagnostic yield of endoscopy. Further studies are needed to suggest the best surveillance program and the appropriate therapeutic modality for these patients.
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Affiliation(s)
- Massimo Picasso
- Department of Gastroenterology, Sanremo Hospital, Corso Garibaldi 187, 3, 18038, Sanremo (IM), Italy
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Hurlstone DP, Sanders DS, Thomson M. Detection and treatment of early flat and depressed colorectal cancer using high-magnification chromoscopic colonoscopy: a change in paradigm for Western endoscopists? Dig Dis Sci 2007; 52:1387-93. [PMID: 17415641 DOI: 10.1007/s10620-006-9460-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Accepted: 05/17/2006] [Indexed: 01/07/2023]
Abstract
Japanese researchers reported flat and depressed colorectal lesions in the 1980s. Such lesions were thought irrelevant to Western populations and described as "Phantom" or "Akitas" carcinoma. Many depressed neoplasms arise through the de novo pathogenic sequence and demonstrate early invasive characteristics. All investigators report difficulties in identifying flat and depressed lesions using conventional colonoscopy. Failure to detect and treat such lesions may be responsible for the current shortfalls in secondary colorectal cancer prevention. Given the introduction of colorectal cancer screening programs in the United Kingdom, Europe, and the United States, it is essential to re-evaluate the significance of flat lesions as applicable to Western cohorts and explore the safety and efficacy of new endoscopic technology and interventional therapeutics.
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Affiliation(s)
- David Paul Hurlstone
- Department of Endoscopy, Royal Hallamshire Hospital, 17 Alexandra Gardens, Lyndhurst Road, Nether Edge, Sheffield, UK.
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Nagata K, Endo S, Tatsukawa K, Kudo SE. Intraoperative fluoroscopy vs. intraoperative laparoscopic ultrasonography for early colorectal cancer localization in laparoscopic surgery. Surg Endosc 2007; 22:379-85. [PMID: 17522916 DOI: 10.1007/s00464-007-9415-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2007] [Revised: 03/05/2007] [Accepted: 03/14/2007] [Indexed: 12/25/2022]
Abstract
BACKGROUND In colorectal cancer (CRC) surgery, precise tumor localization is important for oncologically correct surgery and adequate tumor and lymph node resection margins. During laparoscopic surgery it is difficult to localize early CRC. The aim of this study was to compare the usefulness of two tumor localization techniques; intraoperative fluoroscopy and intraoperative laparoscopic ultrasonography. METHODS Seventeen patients with CRC necessitating preoperative marking were alternately allocated to either the fluoroscopy (F) group (n = 8) or the laparoscopic ultrasonography (LU) group (n = 9). A three-step technique was used. At first lesions were localized preoperatively by metallic clips that were colonoscopically applied proximally and distally to the tumor site. Second, computed tomography (CT) colonography was taken to obtain preoperative staging. The location of the metallic clips was confirmed by CT colonography, preoperatively. Third, in the F group, intraoperative fluoroscopy was performed to localize the applied clips. In the LU group, the applied clips were detected from the serosal aspect of the colon using intraoperative laparoscopic ultrasonography. RESULTS In all patients, colonoscopic metallic clips were successfully applied and preoperative CT colonography correctly detected the location of the tumor. Marking sites were detected precisely using intraoperative fluoroscopy or intraoperative laparoscopic ultrasonography in all cases, without complications. The mean detection time was 15.8 minutes in the F group and 7.0 minutes in the LU group (p = 0.005). In the LU group, two cases were technically difficult because of interruption of the ultrasound by intestinal air. CONCLUSIONS Both intraoperative fluoroscopy and intraoperative laparoscopic ultrasonography are safe and accurate techniques for intraoperative localization of early CRC. With regard to detection time, intraoperative laparoscopic ultrasonography is superior to intraoperative fluoroscopy. However, when there is a massive amount of intestinal air, intraoperative laparoscopic ultrasonography is cumbersome in localizing the lesion. Computed tomography colonography is useful for preoperative tumor localization and might be effective for shortening detection time during surgery.
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Affiliation(s)
- Koichi Nagata
- Digestive Disease Center, Showa University Northern Yokohama Hospital, 35-1, Chigasaki-chuo, Tsuzuki-ku, Yokohama, 224-8503, Japan.
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Alencar H, Funovics MA, Figueiredo J, Sawaya H, Weissleder R, Mahmood U. Colonic adenocarcinomas: near-infrared microcatheter imaging of smart probes for early detection--study in mice. Radiology 2007; 244:232-8. [PMID: 17507718 DOI: 10.1148/radiol.2441052114] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE To prospectively evaluate the ability of micro-fiberoptic catheters, which simultaneously record white light and near-infrared (NIR) images, to reveal colonic neoplasms after the intravenous administration of activatable "smart" probes that increase in NIR fluorescence subsequent to protease activation. MATERIALS AND METHODS The institutional animal care committee approved all animal experiments. CT26 tumor cells were orthotopically implanted into the descending colon of C57BL6/J mice (n=10). Thirteen days later, mice intravenously received either 2 nmol of a protease-sensing probe that had cathepsin B as a major activator (n=5) or saline (control animals [n=5]). One day later, animals were noninvasively examined to the point of the splenic flexure by using microcatheter imaging. Excised colons were subsequently evaluated with epifluorescence imaging, histologic examination, and cathepsin B immunohistochemistry. Student t test was used for statistical analysis, with P<.05 considered to indicate a significant difference. RESULTS Results with fiberoptic imaging demonstrated that all tumors were visible with the protease-activatable probe, even when they were not readily apparent at white light imaging. A target-to-background ratio (TBR) of 8.86 for tumor to adjacent normal mucosa was achieved in the NIR channel after probe administration (P=.001), whereas white light images resulted in a TBR of 1.14 (P>.5) based on luminosity. The tumoral NIR fluorescence intensity was more than 30-fold greater in probe-injected animals than in control animals, indicating that essentially all of the signal recorded in lesions was from activatable probe administration. Results of immunohistochemistry confirmed cathepsin B overexpression in the tumor compared with adjacent mucosa. CONCLUSION The use of NIR imaging microcatheters combined with protease-activatable smart probes results in a beacon effect that highlights tumors with high TBRs; this technique thus may be a potentially useful adjunct to white light colonoscopy in the future.
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Affiliation(s)
- Herlen Alencar
- Center for Molecular Imaging Research, Massachusetts General Hospital, Harvard Medical School, Bldg 149, 13th St, Room 5408, Charlestown, MA 02129, USA
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Atkinson RJ, Shorthouse AJ, Hurlstone DP. Novel colorectal endoscopic in vivo imaging and resection practice: a short practice guide for interventional endoscopists. Tech Coloproctol 2007; 11:7-16. [PMID: 17357860 PMCID: PMC2779445 DOI: 10.1007/s10151-007-0319-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2006] [Accepted: 11/19/2006] [Indexed: 12/19/2022]
Abstract
Colorectal cancer remains a leading cause of cancer death in the UK. With the advent of screening programmes and developing techniques designed to treat and stage colorectal neoplasia, there is increasing pressure on the colonoscopist to keep up to date with the latest practices in this area. This review looks at the basic principles behind endoscopic mucosal resection and forward to the potential endoscopic tools, including high-magnification chromoscopic colonoscopy, high-frequency miniprobe ultrasound and confocal laser scanning endomicroscopic colonoscopy, that may soon become part of routine colorectal cancer management.
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Affiliation(s)
- R J Atkinson
- Department of Endoscopy, Royal Hallamshire Hospital, Sheffield, UK.
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Hurlstone DP, Hunter MD, Sanders DS, Thomson M, Cross SS. Olympus Lucera high-resolution vascular ectasia mapping in combination with the type V crypt pattern for the invasive depth estimation and nodal disease estimation in Paris type II colorectal cancers: a comparative prospective analysis to 20 MHz ultrasound. J Clin Gastroenterol 2007; 41:178-84. [PMID: 17245217 DOI: 10.1097/01.mcg.0000225679.06971.bb] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Flat and depressed neoplastic lesions of the colorectum [Paris type (PT) 0-II] localized to the superficial submucosal (sm) layer can be managed using endoscopic mucosal resection. Successful endoluminal management can be enhanced using endoscopic or ultrasound tools that help predict the degree of sm invasion. Previous studies addressing invasive depth estimation using high-magnification chromoscopic colonoscopy showed a low specificity for deep sm layer 3 invasion with miniprobe ultrasound demonstrating better nodal and T stage in vivo prediction. High-resolution vascular mapping of lesions can show microvascular superficial changes that may predict sm invasive disease. AIMS Vascular mapping in combination with high-magnification chromoscopic colonoscopy (HMCC) may provide an accurate tool for the invasive depth estimation of PT type II neoplastic lesions as compared with high frequency 20/12.5 MHz miniprobe ultrasound. METHODS Sixty-eight patients with a known diagnosis of PT II neoplasia were imaged using 3 "back to back" imaging modalities. Phase 1-vascular ectasia mapping; phase 2-HMCC with crypt analysis according to Nagata criteria; phase 3-12.5/20 MHz miniprobe ultrasound. Lesions predicted as T0/1/N0 were resected using endoscopic mucosal resection with the remaining referred for surgery. Each imaging modality was then compared with the resected histopathologic specimen used as the "gold standard." RESULTS N=68 lesions (19 sm1/13 sm2/36 sm3). Overall accuracy of Nagata criteria, Nagata criteria combined with vascular mapping, and ultrasound staging was 65%, 78%, and 94%, respectively (P<0.001) when observing the between phase differences. Fifty-two lesions were resected surgically. The prevalence of node positive disease was 16% (8/52) with the remaining 44/52 (84%) being confirmed pN0 at histopathology. The kappa coefficient of agreement between invasive depth estimation (using histopathology as the gold standard), Nagata stage, Nagata stage plus vascular ectasia mapping and ultrasound stage was 0.47, 0.65, and 0.9, respectively. A significant improvement in between phase differences was observed (P=0.001). CONCLUSIONS This is the first study to address the in vivo clinical utility of vascular mapping in combination with HMCC for the T and N staging of PT II neoplasia. Combination imaging may provide an adequate clinical tool for both T and N stage assessment in vivo and help stratify those patients at high risk for T2/N1 disease that may benefit from further high-frequency miniprobe ultrasound (HFUS) assessment and possible primary surgical excision. This is important in the clinical context, given the high overall costs of a second HFUS examination, limitation of HFUS resources, and safe selection of patients undergoing primary endoscopic resection versus surgical resection.
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Affiliation(s)
- David P Hurlstone
- Gastroenterology and Liver Unit at the Royal Hallamshire Hospital, Sheffield, South Yorkshire, UK.
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Gualco G, Reissenweber N, Cliché I, Bacchi CE. Flat elevated lesions of the colon and rectum: a spectrum of neoplastic and nonneoplastic entities. Ann Diagn Pathol 2007; 10:333-8. [PMID: 17126250 DOI: 10.1016/j.anndiagpath.2006.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The aim of this prospective study is to establish the frequency and the type (neoplastic and nonneoplastic) lesions defined endoscopically as flat elevated lesion (FEL) in the colon and rectum, as well as to compare flat adenomas (FAs) to polypoid lesions of the same size with morphometric and immunohistochemical analysis. One hundred nineteen patients were studied through fibrocolonoscopy with chromoscopy (indigo carmine spray). All detected lesions (total of 195) were removed, and FELs measuring 10 mm or smaller were also selected. Using histopathologic criteria, they were divided in neoplastic (adenomas and carcinomas) and nonneoplastic ones. In neoplastic lesions, the following parameters were evaluated to compare FAs with polypoid lesions: morphometric studies with Index of Structural Atypia (ISA) and Stratification Index (SI), evaluation of cellular proliferation with label index of Ki-67, and expression of p53 protein. Of 195 lesions resected, only 33 (17%) met the endoscopic requirements for FELs. Twelve (36.4%) were neoplastic and 21 (63.6%) considered nonneoplastic. Among the FAs, there were a percentage of high-grade (severe dysplasia) significantly more frequent than observed in polypoid lesions (16.7% vs 2.6%). In addition, the SI, Ki-67 label index and p53 positivity were significantly higher in FAs. The ISA also reached significant differences between both groups of adenomas. Non-neoplastic FELs included different entities such as hyperplasic polyps, focuses of colitis, normal mucosa, and scars. The endoscopic elements analyzed were shared between nonneoplastic FELs and FAs. A central depression, when air was properly insufflated, considered typical in neoplastic lesions, was frequently observed in nonneoplastic lesions. Following the endoscopic criteria of FELs, nonneoplastic lesions predominated over the adenomatous lesions, demonstrating that FELs and FAs are not homologous terms. The frequency of high-grade dysplasia was significantly more elevated in the adenomatous FELs than in polypoid adenomas. The ISA, SI, p53 expression, and Ki-67 label index were helpful in differentiating adenomatous FELs from polypoid lesions. Flat elevated lesions selected by endoscopic criteria are, in fact, a heterogeneous population of lesions.
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Affiliation(s)
- Gabriela Gualco
- Department of Pathology, Armed Forces Hospital, Montevideo 10000, Uruguay
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Abstract
Abstract
Background
Optical techniques using previously unexploited properties of light interaction with tissue may be valuable in the detection, diagnosis and staging of colorectal neoplasia.
Methods
A Medline search (1990 to present) was conducted on optical diagnostics in the detection of colorectal neoplasia. The reference list of each identified article was reviewed for further relevant papers.
Results and conclusion
Chromoendoscopy is the only optical adjunct to colonoscopy that has been tested in large randomized clinical trials. It improves the detection of small and flat colorectal adenomas, and of neoplasia in chronic ulcerative colitis and hereditary non-polyposis colorectal cancer. All other techniques are the subject of ongoing research and the practicality of population screening with any of the methods has yet to be established. Optical techniques may, however, permit immediate clinical diagnosis, removing the need for histological analysis. They may also improve the diagnosis of early colonic neoplasia.
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Affiliation(s)
- J C Taylor
- Department of Colorectal Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
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