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Dekkers N, Dang H, Vork K, Langers AMJ, van der Kraan J, Westerterp M, Peeters KCMJ, Holman FA, Koch AD, de Graaf W, Didden P, Moons LMG, Doornebosch PG, Hardwick JCH, Boonstra JJ. Outcome of Completion Surgery after Endoscopic Submucosal Dissection in Early-Stage Colorectal Cancer Patients. Cancers (Basel) 2023; 15:4490. [PMID: 37760458 PMCID: PMC10526268 DOI: 10.3390/cancers15184490] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
T1 colorectal cancers (T1CRC) are increasingly being treated by endoscopic submucosal dissection (ESD). After ESD of a T1CRC, completion surgery is indicated in a subgroup of patients. Currently, the influence of ESD on surgical morbidity and mortality is unknown. The aim of this study was to compare 90-day morbidity and mortality of completion surgery after ESD to primary surgery. The completion surgery group consisted of suspected T1CRC patients from a multicenter prospective ESD database (2014-2020). The primary surgery group consisted of pT1CRC patients from a nationwide surgical registry (2017-2019). Patients with rectal or sigmoidal cancers were selected. Patients receiving neoadjuvant therapy were excluded. Propensity score adjustment was used to correct for confounders. In total, 411 patients were included: 54 in the completion surgery group (39 pT1, 15 pT2) and 357 in the primary surgery group with pT1CRC. Adverse event rate was 24.1% after completion surgery and 21.3% after primary surgery. After completion surgery 90-day mortality did not occur, though one patient died in the primary surgery group. After propensity score adjustment, lymph node yield did not differ significantly between the groups. Among other morbidity-related outcomes, stoma rate (OR 1.298 95%-CI 0.587-2.872, p = 0.519) and adverse event rate (OR 1.162; 95%-CI 0.570-2.370, p = 0.679) also did not differ significantly. A subgroup analysis was performed in patients undergoing rectal surgery. In this subgroup (37 completion and 136 primary surgery), these morbidity outcomes also did not differ significantly. In conclusion, this study suggests that ESD does not compromise morbidity or 90-day mortality of completion surgery.
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Affiliation(s)
- Nik Dekkers
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands (J.J.B.)
| | - Hao Dang
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands (J.J.B.)
| | - Katinka Vork
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands (J.J.B.)
| | - Alexandra M. J. Langers
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands (J.J.B.)
| | - Jolein van der Kraan
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands (J.J.B.)
| | - Marinke Westerterp
- Department of Surgery, Haaglanden Medical Center, 2512 VA The Hague, The Netherlands
| | - Koen C. M. J. Peeters
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Fabian A. Holman
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Arjun D. Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Wilmar de Graaf
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Leon M. G. Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Pascal G. Doornebosch
- Department of Surgery, IJsselland Hospital, 2906 ZC Capelle aan den IJssel, The Netherlands
| | - James C. H. Hardwick
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands (J.J.B.)
| | - Jurjen J. Boonstra
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands (J.J.B.)
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Dang H, Dekkers N, Steyerberg EW, Baldaque-Silva F, Omae M, Haasnoot KJ, van Tilburg L, Nobbenhuis K, van der Kraan J, Langers AM, van Hooft JE, de Graaf W, Koch AD, Didden P, Moons LM, Hardwick JC, Boonstra JJ. Predicting procedure duration of colorectal endoscopic submucosal dissection at Western endoscopy centers. Endosc Int Open 2023; 11:E724-E732. [PMID: 37941732 PMCID: PMC10629487 DOI: 10.1055/a-2122-0419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 06/27/2023] [Indexed: 11/10/2023] Open
Abstract
Background and study aims Overcoming logistical obstacles for the implementation of colorectal endoscopic submucosal dissection (ESD) requires accurate prediction of procedure times. We aimed to evaluate existing and new prediction models for ESD duration. Patients and methods Records of all consecutive patients who underwent single, non-hybrid colorectal ESDs before 2020 at three Dutch centers were reviewed. The performance of an Eastern prediction model [GIE 2021;94(1):133-144] was assessed in the Dutch cohort. A prediction model for procedure duration was built using multivariable linear regression. The model's performance was validated using internal validation by bootstrap resampling, internal-external cross-validation and external validation in an independent Swedish ESD cohort. Results A total of 435 colorectal ESDs were analyzed (92% en bloc resections, mean duration 139 minutes, mean tumor size 39 mm). The performance of current unstandardized time scheduling practice was suboptimal (explained variance: R 2 =27%). We successfully validated the Eastern prediction model for colorectal ESD duration <60 minutes (c-statistic 0.70, 95% CI 0.62-0.77), but this model was limited due to dichotomization of the outcome and a relatively low frequency (14%) of ESDs completed <60 minutes in the Dutch centers. The model was more useful with a dichotomization cut-off of 120 minutes (c-statistic: 0.75; 88% and 17% of "easy" and "very difficult" ESDs completed <120 minutes, respectively). To predict ESD duration as continuous outcome, we developed and validated the six-variable cESD-TIME formula ( https://cesdtimeformula.shinyapps.io/calculator/ ; optimism-corrected R 2 =61%; R 2 =66% after recalibration of the slope). Conclusions We provided two useful tools for predicting colorectal ESD duration at Western centers. Further improvements and validations are encouraged with potential local adaptation to optimize time planning.
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Affiliation(s)
- Hao Dang
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Nik Dekkers
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Ewout W. Steyerberg
- Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Francisco Baldaque-Silva
- Endoscopy Unit, Center for Upper Digestive Diseases, Karolinska Hospital, Stockholm, Sweden
- Advanced Endoscopy Center Carlos Moreira da Silva, Pedro Hispano Hospital, Matosinhos, Portugal
| | - Masami Omae
- Endoscopy Unit, Center for Upper Digestive Diseases, Karolinska Hospital, Stockholm, Sweden
| | - Krijn J.C. Haasnoot
- Gastroenterology & Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Kate Nobbenhuis
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Jolein van der Kraan
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Jeanin E. van Hooft
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Wilmar de Graaf
- Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands
| | - Arjun D. Koch
- Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands
| | - Paul Didden
- Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Leon M.G. Moons
- Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - James C.H. Hardwick
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Jurjen J. Boonstra
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
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Dang H, Dekkers N, Steyerberg EW, Baldaque-Silva F, Omae M, Haasnoot KJ, van Tilburg L, Nobbenhuis K, van der Kraan J, Langers AM, van Hooft JE, de Graaf W, Koch AD, Didden P, Moons LM, Hardwick JC, Boonstra JJ. Correction: Predicting procedure duration of colorectal endoscopic submucosal dissection at Western endoscopy centers. Endosc Int Open 2023; 11:C5. [PMID: 37576943 PMCID: PMC10415049 DOI: 10.1055/a-2150-5897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2023] Open
Abstract
[This corrects the article DOI: 10.1055/a-2122-0419.].
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Affiliation(s)
- Hao Dang
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Nik Dekkers
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Ewout W. Steyerberg
- Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Francisco Baldaque-Silva
- Endoscopy Unit, Center for Upper Digestive Diseases, Karolinska Hospital, Stockholm, Sweden
- Advanced Endoscopy Center Carlos Moreira da Silva, Pedro Hispano Hospital, Matosinhos, Portugal
| | - Masami Omae
- Endoscopy Unit, Center for Upper Digestive Diseases, Karolinska Hospital, Stockholm, Sweden
| | - Krijn J.C. Haasnoot
- Gastroenterology & Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Kate Nobbenhuis
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Jolein van der Kraan
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Jeanin E. van Hooft
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Wilmar de Graaf
- Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands
| | - Arjun D. Koch
- Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands
| | - Paul Didden
- Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Leon M.G. Moons
- Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - James C.H. Hardwick
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Jurjen J. Boonstra
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
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4
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Hanevelt J, Huisman JF, Leicher LW, Lacle MM, Richir MC, Didden P, Geesing JMJ, Smakman N, Sive Droste JST, Ter Borg F, Talsma AK, Schrauwen RWM, van Wely BJ, Schot I, Vermaas M, Bos P, Sietses C, Hazen WL, Wasowicz DK, Ploeg DE, Ramsoekh D, Tuynman JB, Alderlieste YA, Renger RJ, Schreuder RM, Bloemen JG, van Lijnschoten I, Consten ECJ, Sikkenk DJ, Schwartz MP, Vos A, Burger JPW, Spanier BWM, Knijn N, Cappel WHDVTN, Moons LMG, van Westreenen HL. Correction: Limited wedge resection for T1 colon cancer (LIMERIC-II trial) - rationale and study protocol of a prospective multicenter clinical trial. BMC Gastroenterol 2023; 23:256. [PMID: 37501070 PMCID: PMC10375605 DOI: 10.1186/s12876-023-02905-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Affiliation(s)
- Julia Hanevelt
- Department of Gastroenterology and Hepatology, Dokter Van Heesweg 2, Isala, Zwolle, 28025 AB, The Netherlands.
| | - Jelle F Huisman
- Department of Gastroenterology and Hepatology, Dokter Van Heesweg 2, Isala, Zwolle, 28025 AB, The Netherlands
| | - Laura W Leicher
- Department of Gastroenterology and Hepatology, Dokter Van Heesweg 2, Isala, Zwolle, 28025 AB, The Netherlands
| | - Miangela M Lacle
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Milan C Richir
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joost M J Geesing
- Department of Gastroenterology & Hepatology, Diakonessenhuis Hospital, Utrecht, The Netherlands
| | - Niels Smakman
- Department of Surgery, Diakonessenhuis Hospital, Utrecht, The Netherlands
| | | | - Frank Ter Borg
- Department of Gastroenterology & Hepatology, Deventer Ziekenhuis, Deventer, The Netherlands
| | - A Koen Talsma
- Department of Surgery, Deventer Ziekenhuis, Deventer, The Netherlands
| | - Ruud W M Schrauwen
- Department of Gastroenterology & Hepatology, Ziekenhuis Bernhoven, Uden, The Netherlands
| | - Bob J van Wely
- Department of Surgery, Ziekenhuis Bernhoven, Uden, The Netherlands
| | - Ingrid Schot
- Department of Gastroenter ology & Hepatology, IJsselland Ziekenhuis, Capelle a/d Ijssel, The Netherlands
| | - Maarten Vermaas
- Department of Surgery, IJsselland Ziekenhuis, Capellle a/d Ijssel, The Netherlands
| | - Philip Bos
- Department of Gastroenterology & Hepatology, Ziekenhuis Gelderse Vallei, Ede, The Netherlands
| | - Colin Sietses
- Department of Surgery, Ziekenhuis Gelderse Vallei, Ede, The Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology & Hepatology, Elisabeth-Tweesteden Ziekenhuis, Tilburg, The Netherlands
| | - Dareczka K Wasowicz
- Department of Surgery, Elisabeth-Tweesteden Ziekenhuis, Tilburg, The Netherlands
| | - David E Ploeg
- Department of Pathology, Elisabeth-Tweesteden Ziekenhuis, Tilburg, The Netherlands
| | - Dewkoemar Ramsoekh
- Department of Gastroenterology & Hepatology, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Yasser A Alderlieste
- Department of Gastroenterology & Hepatology, Beatrixziekenhuis - Rivas, Gorinchem, The Netherlands
| | - Rutger-Jan Renger
- Department of Surgery, Beatrixziekenhuis - Rivas, Gorinchem, The Netherlands
| | - Ramon-Michel Schreuder
- Department of Gastroenterology & Hepatology, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Johanne G Bloemen
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | | | - Esther C J Consten
- Department of Surgery, Meander Medisch Centrum, Amersfoort, The Netherlands
| | - Daan J Sikkenk
- Department of Surgery, Meander Medisch Centrum, Amersfoort, The Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology & Hepatology, Meander Medisch Centrum, Amersfoort, The Netherlands
| | - Annelotte Vos
- Department of Pathology, Meander Medisch Centrum, Amersfoort, The Netherlands
| | - Jordy P W Burger
- Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands
| | - Bernhard W M Spanier
- Department of Gastroenterology & Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Nikki Knijn
- Pathology DNA, Location Arnhem, The Netherlands
| | | | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
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5
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Hanevelt J, Huisman JF, Leicher LW, Lacle MM, Richir MC, Didden P, Geesing JMJ, Smakman N, Droste JSTS, Ter Borg F, Talsma AK, Schrauwen RWM, van Wely BJ, Schot I, Vermaas M, Bos P, Sietses C, Hazen WL, Wasowicz DK, van der Ploeg DE, Ramsoekh D, Tuynman JB, Alderlieste YA, Renger RJ, Schreuder RM, Bloemen JG, van Lijnschoten I, Consten ECJ, Sikkenk DJ, Schwartz MP, Vos A, Burger JPW, Spanier BWM, Knijn N, de Vos Tot Nederveen Cappel WH, Moons LMG, van Westreenen HL. Limited wedge resection for T1 colon cancer (LIMERIC-II trial) - rationale and study protocol of a prospective multicenter clinical trial. BMC Gastroenterol 2023; 23:214. [PMID: 37337197 PMCID: PMC10278298 DOI: 10.1186/s12876-023-02854-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/13/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND The sole presence of deep submucosal invasion is shown to be associated with a limited risk of lymph node metastasis. This justifies a local excision of suspected deep submucosal invasive colon carcinomas (T1 CCs) as a first step treatment strategy. Recently Colonoscopy-Assisted Laparoscopic Wedge Resection (CAL-WR) has been shown to be able to resect pT1 CRCs with a high R0 resection rate, but the long term outcomes are lacking. The aim of this study is to evaluate the safety, effectiveness and long-term oncological outcomes of CAL-WR as primary treatment for patients with suspected superficial and also deeply-invasive T1 CCs. METHODS In this prospective multicenter clinical trial, patients with a macroscopic and/or histologically suspected T1 CCs will receive CAL-WR as primary treatment in order to prevent unnecessary major surgery for low-risk T1 CCs. To make a CAL-WR technically feasible, the tumor may not include > 50% of the circumference and has to be localized at least 25 cm proximal from the anus. Also, there should be sufficient distance to the ileocecal valve to place a linear stapler. Before inclusion, all eligible patients will be assessed by an expert panel to confirm suspicion of T1 CC, estimate invasion depth and subsequent advise which local resection techniques are possible for removal of the lesion. The primary outcome of this study is the proportion of patients with pT1 CC that is curatively treated with CAL-WR only and in whom thus organ-preservation could be achieved. Secondary outcomes are 1) CAL-WR's technical success and R0 resection rate for T1 CC, 2) procedure-related morbidity and mortality, 3) 5-year overall and disease free survival, 4) 3-year metastasis free survival, 5) procedure-related costs and 6) impact on quality of life. A sample size of 143 patients was calculated. DISCUSSION CAL-WR is a full-thickness local resection technique that could also be effective in removing pT1 colon cancer. With the lack of current endoscopic local resection techniques for > 15 mm pT1 CCs with deep submucosal invasion, CAL-WR could fill the gap between endoscopy and major oncologic surgery. The present study is the first to provide insight in the long-term oncological outcomes of CAL-WR. TRIAL REGISTRATION CCMO register (ToetsingOnline), NL81497.075.22, protocol version 2.3 (October 2022).
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Affiliation(s)
- Julia Hanevelt
- Department of Gastroenterology and Hepatology, Isala, Dokter Van Heesweg 2, 28025 AB, Zwolle, The Netherlands.
| | - Jelle F Huisman
- Department of Gastroenterology and Hepatology, Isala, Dokter Van Heesweg 2, 28025 AB, Zwolle, The Netherlands
| | - Laura W Leicher
- Department of Gastroenterology and Hepatology, Isala, Dokter Van Heesweg 2, 28025 AB, Zwolle, The Netherlands
| | - Miangela M Lacle
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Milan C Richir
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joost M J Geesing
- Department of Gastroenterology & Hepatology, Diakonessenhuis Hospital, Utrecht, The Netherlands
| | - Niels Smakman
- Department of Surgery, Diakonessenhuis Hospital, Utrecht, The Netherlands
| | | | - Frank Ter Borg
- Department of Gastroenterology & Hepatology, Deventer Ziekenhuis, Deventer, The Netherlands
| | - A Koen Talsma
- Department of Surgery, Deventer Ziekenhuis, Deventer, The Netherlands
| | - Ruud W M Schrauwen
- Department of Gastroenterology & Hepatology, Ziekenhuis Bernhoven, Uden, The Netherlands
| | - Bob J van Wely
- Department of Surgery, Ziekenhuis Bernhoven, Uden, The Netherlands
| | - Ingrid Schot
- Department of Gastroenterology & Hepatology, IJsselland Ziekenhuis, Capelle a/d Ijssel, The Netherlands
| | - Maarten Vermaas
- Department of Surgery, IJsselland Ziekenhuis, Capellle a/d Ijssel, The Netherlands
| | - Philip Bos
- Department of Gastroenterology & Hepatology, Ziekenhuis Gelderse Vallei, Ede, The Netherlands
| | - Colin Sietses
- Department of Surgery, Ziekenhuis Gelderse Vallei, Ede, The Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology & Hepatology, Elisabeth-Tweesteden Ziekenhuis, Tilburg, The Netherlands
| | - Dareczka K Wasowicz
- Department of Surgery, Elisabeth-Tweesteden Ziekenhuis, Tilburg, The Netherlands
| | | | - Dewkoemar Ramsoekh
- Department of Gastroenterology & Hepatology, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Yasser A Alderlieste
- Department of Gastroenterology & Hepatology, Beatrixziekenhuis - Rivas, Gorinchem, The Netherlands
| | - Rutger-Jan Renger
- Department of Surgery, Beatrixziekenhuis - Rivas, Gorinchem, The Netherlands
| | - Ramon-Michel Schreuder
- Department of Gastroenterology & Hepatology, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Johanne G Bloemen
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | | | - Esther C J Consten
- Department of Surgery, Meander Medisch Centrum, Amersfoort, The Netherlands
| | - Daan J Sikkenk
- Department of Surgery, Meander Medisch Centrum, Amersfoort, The Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology & Hepatology, Meander Medisch Centrum, Amersfoort, The Netherlands
| | - Annelotte Vos
- Department of Pathology, Meander Medisch Centrum, Amersfoort, The Netherlands
| | - Jordy P W Burger
- Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands
| | - Bernhard W M Spanier
- Department of Gastroenterology & Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Nikki Knijn
- Pathology DNA, Location Arnhem, The Netherlands
| | | | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
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Didden P, Bruijnen RCG, Vonken EJPA, Vleggaar FP. Endoscopic embolization of a refractory bronchobiliary fistula by endoscopic retrograde cholangiography using coils and Histoacryl. Endoscopy 2023; 55:484-485. [PMID: 37105159 PMCID: PMC10139763 DOI: 10.1055/a-2017-9651] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- Paul Didden
- University Medical Center Utrecht, Department of Gastroenterology and Hepatology, Utrecht, Netherlands
| | - Rutger C G Bruijnen
- University Medical Center Utrecht, Department of Radiology, Utrecht, Netherlands
| | - Evert-Jan P A Vonken
- University Medical Center Utrecht, Department of Radiology, Utrecht, Netherlands
| | - Frank P Vleggaar
- University Medical Center Utrecht, Department of Gastroenterology and Hepatology, Utrecht, Netherlands
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7
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Kastelijn JB, Didden P, Bogte A, Moons LMG, Vleggaar FP. Digital single-operator cholangioscopy to guide selective cannulation of complex biliary strictures. Surg Endosc 2022; 36:9476-9480. [PMID: 36261641 PMCID: PMC9652227 DOI: 10.1007/s00464-022-09665-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/18/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Selective cannulation and stenting of complex, tight, and/or angulated biliary strictures under endoscopic retrograde cholangiopancreaticography (ERCP) can be challenging. Digital single-operator cholangioscopy (SOC) may facilitate guidewire advancement through the stricture with endoscopic visual guidance. We aimed to describe a case series on clinical outcomes of this technique for selective cannulation, when used after failed conventional ERCP attempts. METHODS Consecutive patients who underwent therapeutic digital SOC for selective cannulation of biliary strictures after failed conventional ERCP were retrospectively included. RESULTS Ten patients with a malignant (n = 6) or benign (n = 4) biliary stricture were included. Digital SOC-assisted selective guidewire insertion and stent placement across the biliary stricture were technically successful in five (50%) patients. Bilirubin levels improved in all patients with technical success. One (10%) patient developed a post-ERCP pancreatitis. CONCLUSIONS Technically successful cannulation of biliary strictures with digital SOC was achieved in half of patients in whom cannulation with conventional ERCP failed, sparing them more invasive interventions. Stricture opacification during the failed ERCP was seen in all technically successful SOCs.
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Affiliation(s)
- Janine B Kastelijn
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Auke Bogte
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
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Didden P, Bruijnen RCG, Vonken EJPA, Vleggaar FP. Endoscopic embolization of a refractory bronchobiliary fistula by endoscopic retrograde cholangiography using coils and Histoacryl. Endoscopy 2022; 55:E268-E269. [PMID: 36427496 PMCID: PMC9831773 DOI: 10.1055/a-1974-9202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Paul Didden
- University Medical Center Utrecht, Department of Gastroenterology and Hepatology, Utrecht, Netherlands
| | | | | | - Frank P. Vleggaar
- University Medical Center Utrecht, Department of Gastroenterology and Hepatology, Utrecht, Netherlands
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9
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Didden P, van Eijck van Heslinga RAH, Schwartz MP, Arensman LR, Vleggaar FP, de Graaf W, Koch AD, Doukas M, Lacle MM, Moons LMG. Relevance of polyp size for primary endoscopic full-thickness resection of suspected T1 colorectal cancers. Endoscopy 2022; 54:1062-1070. [PMID: 35255517 DOI: 10.1055/a-1790-5539] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND En bloc local excision of suspected T1 colorectal cancer (CRC) provides optimal tumor risk assessment with curative intent. Endoscopic full-thickness resection (eFTR) with an over-the-scope device has emerged as a local excision technique for T1 CRCs, but data on the upper size limit for achieving a histological complete (R0) resection are lacking. We aimed to determine the influence of polyp size on the R0 rate. METHODS eFTR procedures for suspected T1 CRCs performed between 2015 and 2021 were selected from the endoscopy databases of three tertiary centers. The main outcome was R0 resection, defined as tumor- and dysplasia-free margins (≥ 0.1 mm) for both the deep and lateral resection margins. Regression analysis was performed to identify risk factors for R1/Rx resection, mainly focusing on endoscopically estimated polyp size. RESULTS 136 patients underwent eFTR for suspected T1 CRC (median size 15 mm [IQR 13-18 mm]; 83.1 % cancer). The rates of technical success and R0 resection were 87.5 % (119/136; 95 %CI 80.9 %-92.1 %) and 79.7 % (106/136; 95 %CI 72.1 %-85.7 %), respectively. Increasing polyp size was significantly associated with R1/Rx resection (risk ratio 2.35 per 5-mm increase, 95 %CI 1.80-3.07; P < 0.001). The R0 rate was 89.9 % (80/89) for polyps ≤ 15 mm, 71.4 % (25/35) for 16-20 mm, and 11.1 % (1/9) for those > 20 mm. CONCLUSIONS eFTR is associated with a 90 % R0 rate for T1 CRCs of ≤ 15 mm. Performing eFTR for polyps 16-20 mm should depend on access, their mobility, and the availability of alternative resection techniques. eFTR for > 20-mm polyps results in a high R1 rate and should not be recommended.
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Affiliation(s)
- Paul Didden
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - L R Arensman
- Department of Pathology, Meander Medical Center, Amersfoort, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wilmar de Graaf
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Michael Doukas
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, The Netherlands
| | - Miangela M Lacle
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
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10
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Moons LMG, Bastiaansen BAJ, Richir MC, Hazen WL, Tuynman J, Elias SG, Schrauwen RWM, Vleggaar FP, Dekker E, Bos P, Fariña Sarasqueta A, Lacle M, Hompes R, Didden P. Endoscopic intermuscular dissection for deep submucosal invasive cancer in the rectum: a new endoscopic approach. Endoscopy 2022; 54:993-998. [PMID: 35073588 DOI: 10.1055/a-1748-8573] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The risk of lymph node metastasis associated with deep submucosal invasion should be balanced against the mortality and morbidity of total mesorectal excision (TME). Dissection through the submucosa hinders radical deep resection, and full-thickness resection may influence the outcome of completion TME. Endoscopic intermuscular dissection (EID) in between the circular and longitudinal part of the muscularis propria could potentially provide an R0 resection while leaving the rectal wall intact. METHODS In this prospective cohort study, the data of patients treated with EID for suspected deep submucosal invasive rectal cancer between 2018 and 2020 were analyzed. Study outcomes were the percentages of technical success, R0 resection, curative resection, and adverse events. RESULTS 67 patients (median age 67 years; 73 % men) were included. The median lesion size was 25 mm (interquartile range 20-33 mm). The rates of overall technical success, R0 resection, and curative resection were 96 % (95 %CI 89 %-99 %), 81 % (95 %CI 70 %-89 %), and 45 % (95 %CI 33 %-57 %). Only minor adverse events occurred in eight patients (12 %). CONCLUSION EID for deep invasive T1 rectal cancer appears to be feasible and safe, and the high R0 resection rate creates the potential of rectal preserving therapy in 45 % of patients.
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Affiliation(s)
- Leon M G Moons
- Department of Gastroenterology & Hepatology, UMC Utrecht, Utrecht, The Netherlands
| | | | - Milan C Richir
- Department of Surgery, UMC Utrecht, Utrecht, The Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology & Hepatology, Elizabeth Tweesteden Ziekenhuis, Tilburg, The Netherlands
| | - Jurriaan Tuynman
- Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Sjoerd G Elias
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Ruud W M Schrauwen
- Department of Gastroenterology & Hepatology, Bernhoven, Uden, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology & Hepatology, UMC Utrecht, Utrecht, The Netherlands
| | - Evelien Dekker
- Department of Gastroenterology & Hepatology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Philip Bos
- Department of Gastroenterology & Hepatology, Gelderse Vallei, Ede, The Netherlands
| | | | - Miangela Lacle
- Department of Pathology, UMC Utrecht, Utrecht, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Paul Didden
- Department of Gastroenterology & Hepatology, UMC Utrecht, Utrecht, The Netherlands
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11
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van Erpecum KJ, Didden P, Verdonk RC. High risk of complications and mortality in cirrhotic patients with acute pancreatitis. Eur J Intern Med 2022; 102:45-46. [PMID: 35718647 DOI: 10.1016/j.ejim.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 06/14/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Karel J van Erpecum
- Department Gastroenterology and Hepatology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht 3584 CX, the Netherlands.
| | - Paul Didden
- Department Gastroenterology and Hepatology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht 3584 CX, the Netherlands
| | - Robert C Verdonk
- Department Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, the Netherlands
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12
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Van der Voort VRH, Moons LMG, de Graaf W, Schrauwen RWM, Hazen WL, Seerden TCJ, Vleggaar FP, Didden P. Efficacy and safety of cap-assisted endoscopic mucosal resection for treatment of nonlifting colorectal polyps. Endoscopy 2022; 54:509-514. [PMID: 34521120 DOI: 10.1055/a-1559-2391] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND : Suboptimal lifting increases complexity of endoscopic mucosal resection (EMR) for benign colorectal polyps. Cap-assisted EMR (EMR-C) may allow fibrotic polyp tissue to be captured in the snare. This study evaluated the efficacy and safety of EMR-C for benign nonlifting colorectal polyps. METHODS : This was a multicenter study, which prospectively registered all EMR-C procedures (2016-2018) for presumed benign nonlifting colorectal polyps. RESULTS : 70 nonlifting polyps with a median size of 25 mm (interquartile range [IQR] 15-40) were treated with EMR-C. Complete polyp removal was achieved in 68 (97.1 %), including 47 (67.1 %) with EMR-C alone. Overall, 66 polyps showed benign histology, and endoscopic follow-up after a median of 6 months (IQR 6-10) showed recurrence in 19.7 %. First (n = 10) and second (n = 2) benign recurrences were all treated endoscopically. Deep mural injury type III-V occurred in 7.4 % and was treated successfully with clips. CONCLUSION : EMR-C may be an alternative therapeutic option for removal of benign nonlifting polyp tissue. Although recurrence still occurs, repeat endoscopic therapy usually leads to complete polyp clearance.
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Affiliation(s)
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Wilmar de Graaf
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Ruud W M Schrauwen
- Department of Gastroenterology and Hepatology, Bernhoven Hospital, Uden, Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-Twee Steden Hospital, Tilburg, Netherlands
| | - Tom C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
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13
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Turan AS, Moons LMG, Schreuder RM, Schoon EJ, Terhaar Sive Droste JS, Schrauwen RWM, Straathof JW, Bastiaansen BAJ, Schwartz MP, Hazen WL, Alkhalaf A, Allajar D, Hadithi M, van der Spek BW, Heine DGDN, Tan ACITL, de Graaf W, Boonstra JJ, Voogd FJ, Roomer R, de Ridder RJJ, Kievit W, Siersema PD, Didden P, van Geenen EJM. Clip placement to prevent delayed bleeding after colonic endoscopic mucosal resection (CLIPPER): study protocol for a randomized controlled trial. Trials 2021; 22:63. [PMID: 33461579 PMCID: PMC7813164 DOI: 10.1186/s13063-020-04996-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) for large colorectal polyps is in most cases the preferred treatment to prevent progression to colorectal carcinoma. The most common complication after EMR is delayed bleeding, occurring in 7% overall and in approximately 10% of polyps ≥ 2 cm in the proximal colon. Previous research has suggested that prophylactic clipping of the mucosal defect after EMR may reduce the incidence of delayed bleeding in polyps with a high bleeding risk. METHODS The CLIPPER trial is a multicenter, parallel-group, single blinded, randomized controlled superiority study. A total of 356 patients undergoing EMR for large (≥ 2 cm) non-pedunculated polyps in the proximal colon will be included and randomized to the clip group or the control group. Prophylactic clipping will be performed in the intervention group to close the resection defect after the EMR with a distance of < 1 cm between the clips. Primary outcome is delayed bleeding within 30 days after EMR. Secondary outcomes are recurrent or residual polyps and clip artifacts during surveillance colonoscopy after 6 months, as well as cost-effectiveness of prophylactic clipping and severity of delayed bleeding. DISCUSSION The CLIPPER trial is a pragmatic study performed in the Netherlands and is powered to determine the real-time efficacy and cost-effectiveness of prophylactic clipping after EMR of proximal colon polyps ≥ 2 cm in the Netherlands. This study will also generate new data on the achievability of complete closure and the effects of clip placement on scar surveillance after EMR, in order to further promote the debate on the role of prophylactic clipping in everyday clinical practice. TRIAL REGISTRATION ClinicalTrials.gov NCT03309683 . Registered on 13 October 2017. Start recruitment: 05 March 2018. Planned completion of recruitment: 31 August 2021.
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Affiliation(s)
- Ayla S Turan
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute of Health Sciences, Nijmegen, Netherlands.
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Ramon-Michel Schreuder
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | | | - Ruud W M Schrauwen
- Department of Gastroenterology and Hepatology, Bernhoven, Uden, Netherlands
| | - Jan Willem Straathof
- Department of Gastroenterology and Hepatology, Màxima Medical Center, Veldhoven, Netherlands
| | - Barbara A J Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, Netherlands
| | - Daud Allajar
- Department of Gastroenterology and Hepatology, Hospital St. Jansdal, Harderwijk, Netherlands
| | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, Netherlands
| | - Bas W van der Spek
- Department of Gastroenterology and Hepatology, Noordwest Hospital Group, Alkmaar, Netherlands
| | - Dimitri G D N Heine
- Department of Gastroenterology and Hepatology, Noordwest Hospital Group, Alkmaar, Netherlands
| | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius-Wilhelmina hospital, Nijmegen, Netherlands
| | - Wilmar de Graaf
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Jurjen J Boonstra
- Department of Gastroenterology and Hepatology, Leids University Medical Center, Leiden, Netherlands
| | - Fia J Voogd
- Department of Gastroenterology and Hepatology, Medical Center Leeuwarden, Leeuwarden, Netherlands
| | - Robert Roomer
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis, Rotterdam, Netherlands
| | - Rogier J J de Ridder
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Wietske Kievit
- IQ Healthcare, Radboud University Medical Center, Nijmegen, Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute of Health Sciences, Nijmegen, Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud Institute of Health Sciences, Nijmegen, Netherlands
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14
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van der Star S, Moons LM, ter Borg F, van Bergeijk JD, Geesing JM, Groen JN, Ouwehand RJ, Vleggaar FP, de Vos tot Nederveen Cappel WH, Wolfhagen FH, Schwartz MP, Didden P. Management of delayed bleeding after endoscopic mucosal resection of large colorectal polyps: a retrospective multi-center cohort study. Endosc Int Open 2020; 8:E1052-E1060. [PMID: 32743059 PMCID: PMC7373661 DOI: 10.1055/a-1192-3816] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/18/2020] [Indexed: 01/03/2023] Open
Abstract
Background and study aims Delayed bleeding (DB) is the most frequent major adverse event after endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (LNPCPs). Evidence-based guidelines for management of DB are lacking. We aimed to evaluate the clinical presentation, treatment and outcome of patients with DB and to determine factors associated with hemostatic therapy. Patients and methods Patients with DB were identified by analyzing all consecutive EMR procedures for LNPCPs (≥ 2 cm) from one academic center (2012-2017) and seven regional hospitals (2015-2017). DB was defined as any postprocedural bleeding necessitating emergency department presentation, hospitalization or reintervention. Outcome of DB was assessed for three clinical scenarios: continued bleeding (CB), spontaneous resolution without recurrent bleeding during 24 hours observation (SR), and recurrent bleeding (RB). Variables associated with hemostatic therapy were analyzed using logistic regression. Results DB occurred after 42/542 (7.7 %) EMR procedures and re-colonoscopy was performed in 30 patients (72 %). Re-colonoscopy and hemostatic therapy rates were 92 % and 75 % for CB (n = 24), 25 % and 8 % for SR (n = 12), and 83 % and 67 % for RB (n = 6), respectively. Frequent hematochezia (≥ hourly) was the only factor significantly associated with hemostatic therapy (RR 2.23, p = 0.01). Re-bleeding after endoscopic hemostatic therapy occurred in 3/22 (13.6 %) patients. Conclusion Ongoing or recurrent hematochezia is associated with a high rate of hemostatic therapy, warranting re-colonoscopy in these patients. A conservative approach is justified when bleeding spontaneously settles, and without recurrent hematochezia during 24 hours observation patients can be safely discharged without endoscopic re-examination.
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Affiliation(s)
- Simone van der Star
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leon M.G. Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank ter Borg
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, The Netherlands
| | - Jeroen D. van Bergeijk
- Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Joost M.J. Geesing
- Department of Gastroenterology and Hepatology, Diakonessenhuis, Utrecht, The Netherlands
| | - John N. Groen
- Department of Gastroenterology and Hepatology, Sint Jansdal Hospital, Harderwijk, The Netherlands
| | - Renske J. Ouwehand
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank P. Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Frank H.J. Wolfhagen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Matthijs P. Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
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15
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Turan AS, Didden P, Peters Y, Moons LMG, Schreuder RM, Siersema PD, van Geenen EJM. Factors involved in endoscopists' choice for prophylactic clipping after colorectal endoscopic mucosal resection: a discrete choice experiment. Scand J Gastroenterol 2020; 55:737-744. [PMID: 32516002 DOI: 10.1080/00365521.2020.1770851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background: Delayed bleeding (DB) occurs in ∼10% after colorectal EMR. Prophylactic clipping (PC) was reported to significantly decrease DB-rate in proximal lesions ≥2 cm.Objective: Our aim was to determine which predefined variables contribute to using PC in clinical practice.Methods: We performed an international discrete choice experiment (DCE) among ∼500 endoscopists. Relevant variables for PC use were selected by EMR experts: previous DB, anticoagulants, polyp size, morphology, location, intraprocedural bleeding and visible vessel(s). Respondents answered case scenarios with various variable combinations, each time choosing only one scenario for PC, or the 'none' option. Part-worth utilities and importance weights were calculated using HB regression. Subsequently, a predictive model was created to calculate the likelihood of endoscopists choosing PC in any given case.Results: The survey was completed by 190 EMR endoscopists from 17 countries. In total, 8% would never use PC, whereas 30.9% never chose the 'none' option. All variables except polyp type were significant in decision-making for PC (p < .01). The most important factor was anticoagulant use, accounting for 22.5% in decision-making. Polyps <2 cm were considered eligible for PC by 14% in the presence of high-weighing factors such as anticoagulant use. No significant differences were found between high and low-to-moderately experienced endoscopists.Conclusions: PC after EMR is often considered useful by endoscopists, usually based on risk factors for DB. Anticoagulant use was the most important factor in decision-making for PC, independent of endoscopist experience. Although not considered cost-effective, one in seven endoscopists chose PC for adenomas <2 cm.
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Affiliation(s)
- Ayla S Turan
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Research Institute for Health Sciences, Nijmegen, The Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yonne Peters
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Research Institute for Health Sciences, Nijmegen, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ramon-Michel Schreuder
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Research Institute for Health Sciences, Nijmegen, The Netherlands
| | - Erwin J M van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Research Institute for Health Sciences, Nijmegen, The Netherlands
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16
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Kessels K, Backes Y, Elias SG, van den Blink A, Offerhaus GJA, van Bergeijk JD, Groen JN, Seerden TCJ, Schwartz MP, de Vos Tot Nederveen Cappel WH, Spanier BWM, Geesing JMJ, Kerkhof M, Siersema PD, Didden P, Boonstra JJ, Herrero LA, Wolfhagen FHJ, Ter Borg F, van Lent AU, Terhaar Sive Droste JS, Hazen WL, Schrauwen RWM, Vleggaar FP, Laclé MM, Moons LMG. Pedunculated Morphology of T1 Colorectal Tumors Associates With Reduced Risk of Adverse Outcome. Clin Gastroenterol Hepatol 2019; 17:1112-1120.e1. [PMID: 30130623 DOI: 10.1016/j.cgh.2018.08.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 08/02/2018] [Accepted: 08/06/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Risk stratification for adverse events, such as metastasis to lymph nodes, is based only on histologic features of tumors. We aimed to compare adverse outcomes of pedunculated vs nonpedunculated T1 colorectal cancers (CRC). METHODS We performed a retrospective study of 1656 patients diagnosed with T1CRC from 2000 through 2014 at 14 hospitals in The Netherlands. The median follow-up time of patients was 42.5 months (interquartile range, 18.5-77.5 mo). We evaluated the association between tumor morphology and the primary composite end point, adverse outcome, adjusted for clinical variables, histologic variables, resection margins, and treatment approach. Adverse outcome was defined as metastasis to lymph nodes, distant metastases, local recurrence, or residual tissue. Secondary end points were tumor metastasis, recurrence, and incomplete resection. RESULTS Adverse outcome occurred in 67 of 723 patients (9.3%) with pedunculated T1CRCs vs 155 of 933 patients (16.6%) with nonpedunculated T1CRCs. Pedunculated morphology was independently associated with decreased risk of adverse outcome (adjusted odds ratio [OR], 0.59; 95% CI, 0.42-0.83; P = .003). Metastasis, incomplete resection, and recurrence were observed in 5.8%, 4.6%, and 3.9% of pedunculated T1CRCs vs 10.6%, 8.0%, and 6.6% of nonpedunculated T1CRCs, respectively. Pedunculated morphology was independently associated with a reduced risk of metastasis (adjusted OR, 0.62; 95% CI, 0.41-0.94; P = .03), incomplete resection (adjusted OR, 0.57; 95% CI, 0.36-0.91; P = .02), and recurrence (adjusted hazard ratio, 0.52; 95% CI, 0.32-0.85; P = .009). Metastasis, incomplete resection, and recurrence did not differ significantly between low-risk pedunculated vs nonpedunculated T1CRCs (0.8% vs 2.9%, P = .38; 1.5% vs 0%, P = .99; 1.5% vs 0%; P = .99). However, incomplete resection and recurrence were significantly lower for high-risk pedunculated vs nonpedunculated T1CRCs (6.5% vs 12.5%; P = .007; 4.4% vs 8.6%; P = .03). CONCLUSIONS In a retrospective study of patients with T1CRC, we found pedunculated morphology to be associated independently with a decreased risk of adverse outcome in a T1CRC population at high risk of adverse outcome. Incorporating morphologic features of tumors in risk assessment could help predict outcomes of patients with T1CRC and help identify the best candidates for surgery.
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Affiliation(s)
- Koen Kessels
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Yara Backes
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sjoerd G Elias
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Aneya van den Blink
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Critical Care Medicine, Vrije Universiteit University Medical Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - G Johan A Offerhaus
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jeroen D van Bergeijk
- Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, The Netherlands
| | - John N Groen
- Department of Gastroenterology and Hepatology, Sint Jansdal Hospital, Harderwijk, The Netherlands
| | - Tom C J Seerden
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | | | - Bernhard W M Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Joost M J Geesing
- Department of Gastroenterology and Hepatology, Diakonessenhuis Hospital, Utrecht, The Netherlands
| | - Marjon Kerkhof
- Department of Gastroenterology and Hepatology, Groene Hart Hospital, Gouda, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Gastroenterology and Hepatology, Radboud University Medical Center, Radboud University, Nijmegen, The Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jurjen J Boonstra
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Frank H J Wolfhagen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Frank Ter Borg
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, The Netherlands
| | - Anja U van Lent
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis Hospital, Amsterdam, The Netherlands
| | | | - Wouter L Hazen
- Department of Gastroenterology and Hepatology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Ruud W M Schrauwen
- Department of Gastroenterology and Hepatology, Bernhoven Hospital, Uden, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Miangela M Laclé
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
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Backes Y, Schwartz MP, Ter Borg F, Wolfhagen FHJ, Groen JN, de Vos Tot Nederveen Cappel WH, van Bergeijk J, Geesing JMJ, Spanier BWM, Didden P, Vleggaar FP, Lacle MM, Elias SG, Moons LMG. Multicentre prospective evaluation of real-time optical diagnosis of T1 colorectal cancer in large non-pedunculated colorectal polyps using narrow band imaging (the OPTICAL study). Gut 2019; 68:271-279. [PMID: 29298873 DOI: 10.1136/gutjnl-2017-314723] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 11/17/2017] [Accepted: 11/18/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This study evaluated the preresection accuracy of optical diagnosis of T1 colorectal cancer (CRC) in large non-pedunculated colorectal polyps (LNPCPs). DESIGN In this multicentre prospective study, endoscopists predicted the histology during colonoscopy in consecutive patients with LNPCPs using a standardised procedure for optical assessment. The presence of morphological features assessed with white light, and vascular and surface pattern with narrow-band imaging (NBI) were recorded, together with the optical diagnosis, the confidence level of prediction and the recommended treatment. A risk score chart was developed and validated using a multivariable mixed effects binary logistic least absolute shrinkage and selection (LASSO) model. RESULTS Among 343 LNPCPs, 47 cancers were found (36 T1 CRCs and 11 ≥T2 CRCs), of which 11 T1 CRCs were superficial invasive T1 CRCs (23.4% of all malignant polyps). Sensitivity and specificity for optical diagnosis of T1 CRC were 78.7% (95% CI 64.3 to 89.3) and 94.2% (95% CI 90.9 to 96.6), and 63.3% (95% CI 43.9 to 80.1) and 99.0% (95% CI 97.1 to 100.0) for optical diagnosis of endoscopically unresectable lesions (ie, ≥T1 CRC with deep invasion), respectively. A LASSO-derived model using white light and NBI features discriminated T1 CRCs from non-invasive polyps with a cross-validation area under the curve (AUC) of 0.85 (95% CI 0.80 to 0.90). This model was validated in a temporal validation set of 100 LNPCPs (AUC of 0.81; 95% CI 0.66 to 0.96). CONCLUSION Our study provides insights in the preresection accuracy of optical diagnosis of T1 CRC. Sensitivity is still limited, so further studies will show how the risk score chart could be improved and finally used for clinical decision making with regard to the type of endoresection to be used and whether to proceed to surgery instead of endoscopy. TRIAL REGISTRATION NUMBER NTR5561.
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Affiliation(s)
- Yara Backes
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
| | - Frank Ter Borg
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, The Netherlands
| | - Frank H J Wolfhagen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - John N Groen
- Department of Gastroenterology and Hepatology, Sint Jansdal Hospital, Harderwijk, The Netherlands
| | | | - Jeroen van Bergeijk
- Department of Gastroenterology and Hepatology, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Joost M J Geesing
- Department of Gastroenterology and Hepatology, Diakonessenhuis, Utrecht, The Netherlands
| | - Bernhard W M Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Miangela M Lacle
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sjoerd G Elias
- Julius Center for Health Sciences and Primary Care, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
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Reijm AN, Didden P, Schelling SJC, Siersema PD, Bruno MJ, Spaander MCW. Self-expandable metal stent placement for malignant esophageal strictures - changes in clinical outcomes over time. Endoscopy 2019; 51:18-29. [PMID: 29991071 DOI: 10.1055/a-0644-2495] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Self-expandable metal stents (SEMSs) are effective for improving dysphagia in patients with incurable esophageal cancer but are also associated with recurrent dysphagia and adverse events. In the past decades, new SEMSs have been introduced, but also patients' risk profiles have altered. It is unknown if these changes have affected SEMS outcomes. METHODS This retrospective cohort study was conducted in a tertiary referral center in the Netherlands. Patients who underwent palliative esophageal SEMS placement for malignant dysphagia between 1994 and 2017 were included. The primary outcome was to assess shifts over time with respect to recurrent dysphagia and adverse events after SEMS placement. RESULTS 997 patients who underwent SEMS placement were included. Recurrent dysphagia occurred in 309 patients (31 %) and remained stable, although with a trend towards an increase over time (hazard ratio [HR] 1.02 per 1-year increase; P = 0.05). Migration rate significantly increased over time (HR 1.04 per 1-year increase; P = 0.01). SEMS-related complications occurred in 461 patients (46.2 %), with 207 (20.7 %) major and 336 (33.7 %) minor complications. Prior chemoradiotherapy was significantly associated with major complications (HR 1.69; P < 0.001). Pain was the most common adverse event and showed a significant increase over time (P < 0.01). Factors associated with pain were prior chemoradiotherapy, absence of a fistula, axial and radial forces, and squamous cell carcinoma. CONCLUSIONS Despite the introduction of novel esophageal SEMS designs, recurrent dysphagia has not declined over the years. Stent-related complications have increased in recent years, which seems to be mainly associated with more frequent use of chemoradiotherapy prior to SEMS placement.
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Affiliation(s)
- Agnes N Reijm
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sara J C Schelling
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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19
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Didden P, Reijm AN, Erler NS, Wolters LMM, Tang TJ, Ter Borg PCJ, Leeuwenburgh I, Bruno MJ, Spaander MCW. Fully vs. partially covered selfexpandable metal stent for palliation of malignant esophageal strictures: a randomized trial (the COPAC study). Endoscopy 2018; 50:961-971. [PMID: 29895072 DOI: 10.1055/a-0620-8135] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Covered esophageal self-expandable metal stents (SEMSs) are currently used for palliation of malignant dysphagia. The optimal extent of the covering to prevent recurrent obstruction is unknown. Therefore, we aimed to compare fully covered (FC) versus partially covered (PC) SEMSs in patients with incurable malignant esophageal stenosis. METHODS In this multicenter randomized controlled trial, 98 incurable patients with dysphagia caused by a malignant stricture of the esophagus or cardia were randomized 1:1 to an FC-SEMS or PC-SEMS. The primary outcome was recurrent obstruction after endoscopic SEMS placement. Secondary outcomes were technical and clinical success, adverse events, and health-related quality of life (HRQoL). Patients were followed until 6 months after SEMS placement or to SEMS removal, second SEMS insertion, or death, whichever came first. RESULTS Recurrent obstruction after SEMS placement was similar for both types of stents: 19 % for FC-SEMSs and 22 % for PC-SEMSs (P = 0.65). The times to recurrent obstruction did not differ. The frequency of adverse events was similar between the two groups, with major adverse events occurring in 38 % and 47 % of patients for FC-SEMSs and PC-SEMSs, respectively (P = 0.34). No significant differences were seen in technical success, improvement of dysphagia, and HRQoL. Proximal esophageal stenosis and female sex were independently associated with recurrent obstruction and/or major adverse events. CONCLUSIONS Esophageal FC-SEMSs did not reveal a lower recurrent obstruction rate compared with PC-SEMSs in the palliative management of malignant dysphagia.
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Affiliation(s)
- Paul Didden
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Agnes N Reijm
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Leonieke M M Wolters
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Thjon J Tang
- Department of Gastroenterology and Hepatology, IJsselland Hospital, Capelle aan den Ijssel, The Netherlands
| | - Pieter C J Ter Borg
- Department of Gastroenterology and Hepatology, Ikazia Hospital, Rotterdam, The Netherlands
| | - Ivonne Leeuwenburgh
- Department of Gastroenterology and Hepatology, Fransiscus Hospital, Rotterdam, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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20
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Pouw RE, Künzli HT, Bisschops R, Sondermeijer CM, Koch AD, Didden P, Gotink AW, Schoon EJ, Curvers WL, Bergman JJGHM, Weusten BLAM. Simplified versus standard regimen for focal radiofrequency ablation of dysplastic Barrett's oesophagus: a multicentre randomised controlled trial. Lancet Gastroenterol Hepatol 2018; 3:566-574. [PMID: 29934224 DOI: 10.1016/s2468-1253(18)30157-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 04/19/2018] [Accepted: 04/23/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND For focal radiofrequency ablation of Barrett's oesophagus, a simplified regimen (3 × 15 J/cm2, without cleaning) has proven to be as effective as the standard regimen (2 × 15 J/cm2, followed by cleaning, followed by 2 × 15 J/cm2). However, this simplified regimen seemed to be associated with a higher stenosis rate. Therefore, we lowered the radiofrequency energy and hypothesised that this new simplified regimen would be as effective and safe as the standard regimen. METHODS This randomised non-inferiority trial included patients with dysplastic Barrett's oesophagus or residual Barrett's oesophagus after endoscopic resection or circumferential radiofrequency ablation, in five European tertiary referral centres. Patients were randomly assigned (1:1) to the new simplified regimen (3 × 12 J/cm2, without cleaning) or the standard regimen, with variable block sizes of four, six, and eight patients, stratified by participating hospital. Focal radiofrequency ablation was done every 3 months, up to a maximum of three treatments, until all Barrett's oesophagus was eradicated. The primary outcome was complete endoscopic and histological regression of dysplasia and intestinal metaplasia after two focal radiofrequency ablation treatments, assessed in the intention-to-treat population. Non-inferiority was assessed on the basis of the difference between groups in the median percentage of Barrett's oesophagus surface regression, with a non-inferiority margin of -15%. This study is registered with www.trialregister.nl, number NTR4994, and is completed. FINDINGS Between March 25, 2015, and July 25, 2016, 84 patients were randomly assigned to treatment: 44 to receive the simplified regimen and 40 to receive the standard regimen. One patient assigned to the simplified regimen and four assigned to the standard regimen were excluded because they weree found not to be eligible; therefore the final intention-to-treat population consisted of 43 patients in the simplified ablation group and 36 in the standard ablation group. Complete endoscopic and histological regression of dysplasia and intestinal metaplasia after two focal radiofrequency ablation treatments was achieved in 32 (74%, 95% CI 59-87) patients treated with the simplified protocol, versus 30 (83%, 95% CI 67-94) patients treated with the standard protocol (p=0·34). Median Barrett's oesophagus surface regression after two focal radiofrequency ablation sessions was 98% (IQR 95-100) in the simplified regimen group and 100% (97-100) in the standard regimen group. The difference between medians was 2% (95% CI -0·562 to 3·162); thus the simplified regimen was deemed non-inferior to the standard regimen. Stenoses requiring dilatation were observed in four (9%) of 43 patients in the simplified regimen group and four (11%) of 36 in the standard regimen group. Post-procedural bleeding requiring repeat endoscopy occurred in one (2%) patient in the simplified ablation group and three (8%) patients in the standard ablation group. One patient (2%) in the simplified treatment group died 36 days after the second radiofrequency ablation procedure, due to an unknown cause. INTERPRETATION Based on the results of this study, we conclude that the simplified regimen is the preferred regimen for focal radiofrequency ablation of Barrett's oesophagus. FUNDING None.
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Affiliation(s)
- Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | - Hannah T Künzli
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Carine M Sondermeijer
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Anniek W Gotink
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands.
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Gotink AW, Spaander MCW, Doukas M, Tang TJ, Didden P, Wijnhoven BPL, Bruno MJ, Koch AD. Exploring diagnostic and therapeutic implications of endoscopic mucosal resection in EUS-staged T2 esophageal adenocarcinoma. Endoscopy 2017. [PMID: 28637063 DOI: 10.1055/s-0043-112492] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background and study aims Treatment strategies for clinical (c)T2N0M0 esophageal adenocarcinoma (EAC) are subject to debate owing to the relative inaccuracy of tumor staging by endoscopic ultrasound (EUS), with profound implications in overstaged patients. We aimed to evaluate the final histological diagnosis of patients initially staged as having a cT2 tumor by EUS, and to assess the value of endoscopic reassessment by an interventional endoscopist, followed by an endoscopic resection when deemed feasible. Patients and methods Two distinct cohorts of patients with cT2 EAC as determined by EUS were included: a retrospective surgical cohort of patients treated by primary esophagectomy, and a prospective cohort of patients who underwent an endoscopic reassessment by an interventional endoscopist. The main outcome measure was the final pathological (p)T stage. Results We identified 134 patients with stage T2 EAC from the surgical cohort. In 72 patients treated by primary esophagectomy, 32/72 (44 %) were downstaged to a pT1 tumor. In 12/72 (17 %), the surgical resection specimen showed tumor characteristics that fulfilled the current criteria for a curative endoscopic resection. In 13 prospectively identified patients with cT2N0M0 EAC, an expert endoscopic reassessment was done. In 11/13 (85 %) the lesion appeared endoscopically resectable and a complete endoscopic resection was performed. Histology revealed a pT1 tumor in all 11 patients, with 5/13 (38 %) fulfilling current criteria for a curative endoscopic resection. Conclusions In this study, 44 % of cT2 EACs were in fact pT1 tumors. Curative treatment by endoscopic resection was achieved in more than a third of these cases. To avoid an unnecessary esophagectomy, an endoscopic reassessment by an interventional endoscopist is recommended for all patients with cT2N0M0 EAC.
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Affiliation(s)
- Annieke W Gotink
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Michael Doukas
- Department of Pathology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Thjon J Tang
- Department of Gastroenterology and Hepatology, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Reijm AN, Didden P, Bruno MJ, Spaander MC. Early pain detection and management after esophageal metal stent placement in incurable cancer patients: A prospective observational cohort study. Endosc Int Open 2016; 4:E890-4. [PMID: 27540579 PMCID: PMC4988853 DOI: 10.1055/s-0042-111202] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 06/13/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Studies of esophageal self-expandable metal stents (SEMS) mainly focus on efficacy and recurrent dysphagia. Retrosternal pain has been described in up to 14 % of these patients, however, prospective daily pain assessment has not yet been performed. We conducted a prospective study to evaluate the occurrence and management of pain after esophageal SEMS deployment. PATIENTS AND METHODS A total of 65 patients who underwent SEMS placement for incurable malignant esophageal stenosis were included. Patients used a diary to record intensity of pain twice daily for 2 weeks, according to the Numeric Rating Scale (NRS). A pain score ≥ 4 was used to determine whether patients experienced significant pain. If pain occurred, acetaminophen was used and, in cases of ongoing pain, an opiate was prescribed. Dose, duration, and kind of analgesic were noted. RESULTS The rate of significant pain increased from 0 % at baseline to 60 % on Day 1 (P < 0.001), followed by 37 % and 25 % on Days 7 and 14, respectively. The rate of analgesics use increased from 20 % at baseline to 78 % on Day 1 (P < 0.001), followed by 72 % and 62 % on Days 7 and 14, respectively. The use of opiates increased from 14 % at baseline to 42 % on Day 1 (P < 0.001). No variables associated with SEMS related pain were found. CONCLUSIONS Two-thirds of patients experience significant pain after esophageal SEMS insertion and analgesics, including opiates, are frequently required. Patients need to be informed and preventive prescription of analgesia should be considered in order to improve quality of life.
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Affiliation(s)
- Agnes N. Reijm
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Manon C.W. Spaander
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands,Corresponding author Manon C. W. Spaander Department of Gastroenterology and Hepatology (room Hs-312)Erasmus University Medical Centre‘s Gravendijkwal 230, 3015 CE RotterdamThe Netherlands+31 (0) 10 7035643+31 (0) 10 7035172
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Fotis D, Doukas M, Wijnhoven BP, Didden P, Biermann K, Bruno MJ, Koch AD. Submucosal invasion and risk of lymph node invasion in early Barrett's cancer: potential impact of different classification systems on patient management. United European Gastroenterol J 2015; 3:505-13. [PMID: 26668743 DOI: 10.1177/2050640615581965] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Due to the high mortality and morbidity rates of esophagectomy, endoscopic mucosal resection (EMR) is increasingly used for the curative treatment of early low risk Barrett's adenocarcinoma. OBJECTIVE This retrospective cohort study aimed to assess the prevalence of lymph node metastases (LNM) in submucosal (T1b) esophageal adenocarcinomas (EAC) in relation to the absolute depth of submucosal tumor invasion and demonstrate the efficacy of EMR for low risk (well and moderately differentiated without lymphovascular invasion) EAC with sm1 invasion (submucosal invasion ≤500 µm) according to the Paris classification. METHODS The pathology reports of patients undergoing endoscopic resection and surgery from January 1994 until December 2013 at one center were reviewed and 54 patients with submucosal invasion were included. LNM were evaluated in surgical specimens and by follow up examinations in case of EMR. RESULTS No LNM were observed in 10 patients with sm1 adenocarcinomas that underwent endoscopic resection. Three of them underwent supplementary endoscopic eradication therapy with a median follow up of 27 months for patients with sm1 tumors. In the surgical series two patients (29%) with sm1 invasion according to the pragmatic classification (subdivision of the submucosa into three equal thirds), staged as sm2-3 in the Paris classification, had LNM. The rate of LNM for surgical patients with low risk sm1 tumors was 10% according to the pragmatic classification and 0% according to Paris classification. CONCLUSION Different classifications of the tumor invasion depth lead to different LNM risks and treatment strategies for sm1 adenocarcinomas. Patients with low risk sm1 adenocarcinomas appear to be suitable candidates for EMR.
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Affiliation(s)
- Dimitrios Fotis
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Michael Doukas
- Department of Pathology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Bas Pl Wijnhoven
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Katharina Biermann
- Department of Pathology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
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van Adrichem S, Didden P, van Lanschot JJBJ. [A man with chest pain and dyspnoea]. Ned Tijdschr Geneeskd 2015; 159:A8275. [PMID: 25654684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
A 60-year-old man presented with acute chest pain and dyspnoea, which was caused by pericarditis secondary to a neo-oesophago-pericardial fistula after previous oesophagectomy for oesophageal cancer. The fistula presumably originated from a penetrating peptic ulcer.
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Tringali A, Didden P, Repici A, Spaander M, Bourke MJ, Williams SJ, Spicak J, Drastich P, Mutignani M, Perri V, Roy A, Johnston K, Costamagna G. Endoscopic treatment of malignant gastric and duodenal strictures: a prospective, multicenter study. Gastrointest Endosc 2014; 79:66-75. [PMID: 23932009 DOI: 10.1016/j.gie.2013.06.032] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 06/19/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Malignant gastric outlet obstruction is often treated by stent placement. OBJECTIVE To investigate the outcomes of stent placement in the palliative treatment of malignant neoplasms. DESIGN Prospective, observational, multicenter registry. SETTING Six tertiary care centers in 5 countries. PATIENTS A total of 108 adult patients with malignant gastric outlet obstruction. INTERVENTIONS Placement of an uncovered, self-expandable, metal duodenal stent. MAIN OUTCOME MEASUREMENTS The primary endpoint was stent patency at 14 days after stent implantation. Secondary endpoints included stent patency at 1, 2, 3, and 6 months, gastric outlet obstruction scoring system (GOOSS) scores at 14 days and 1, 2, 3, and 6 months after stent deployment, technical success, adverse events, and patient survival (ie, confirmed duration of the implant). RESULTS Technical success was achieved in 99.1% of stent placements. Stent patency at 14 days was 94.6%. Kaplan-Meier estimates of stent patency were 92.9% at 1 month, 86.2% at 2 months, 81.9% at 3 months, and 63.4% at 6 months. At 14 days, GOOSS scores increased by a median of 1 point. The overall GI adverse event rate was 32.4%; however, the stent-related adverse event rate was 19.4%. The median implant duration was 47 days (range 0-195 days). LIMITATIONS Observational study, no control group. CONCLUSIONS Duodenal stent placement resulted in prompt relief of malignant gastric outlet obstruction and improved GOOSS scores. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00991614.).
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Affiliation(s)
| | - Paul Didden
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Alessandro Repici
- Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Manon Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Julius Spicak
- Department of Hepatogastroenterology, IKEM, Prague, Czech Republic
| | - Pavel Drastich
- Department of Hepatogastroenterology, IKEM, Prague, Czech Republic
| | | | - Vincenzo Perri
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
| | - André Roy
- Endoscopy Unit, Centre Hospitalier de l'Université de Montreal (CHUM), Hôpital Saint-Luc, Montréal Québec, Canada
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Abstract
Endoscopic stent placement is an effective palliative treatment for malignant dysphagia and fistula, leading to rapid symptom relief. However, recurrent dysphagia and other stent-related complications are common, for which reason continuously new design modifications are implemented. Although some of these changes facilitate stent placement, complications remain and occur at similar rates. Recently, stents have also been used in benign esophageal disorders. Covered stents have the ability to effectively seal esophageal perforations and leaks, reducing the need for invasive surgery. This benefit does not pertain to patients with refractory benign esophageal strictures, in whom stents have limited long-term effect and are associated with a high complication rate. The initial results of fully covered metal stents in refractory esophageal variceal bleeding are encouraging, but their definite role remains to be further elucidated. This review provides an overview of indications, techniques, and management of complications of stents in malignant and benign esophageal disease.
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Affiliation(s)
- P Didden
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands.
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Didden P, Spaander MCW, de Ridder R, Berk L, van Tilburg AJP, Leeuwenburgh I, Kuipers EJ, Bruno MJ. Efficacy and safety of a partially covered stent in malignant gastric outlet obstruction: a prospective Western series. Gastrointest Endosc 2013; 77:664-8. [PMID: 23290774 DOI: 10.1016/j.gie.2012.10.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 10/17/2012] [Indexed: 02/08/2023]
Affiliation(s)
- Paul Didden
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Didden P, Kuipers EJ, Bruno MJ, Spaander MCW. Endoscopic removal of a broken self-expandable metal stent using the stent-in-stent technique. Endoscopy 2012; 44 Suppl 2 UCTN:E232. [PMID: 22715009 DOI: 10.1055/s-0032-1306795] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- P Didden
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
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Didden P, Spaander MCW, Kuipers EJ, Bruno MJ. Safety of stent placement in recurrent or persistent esophageal cancer after definitive chemoradiotherapy: a case series. Gastrointest Endosc 2012; 76:426-30. [PMID: 22657402 DOI: 10.1016/j.gie.2012.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Accepted: 03/05/2012] [Indexed: 02/08/2023]
Affiliation(s)
- Paul Didden
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
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Didden P, Spaander MCW, Wijnhoven BPL, Kuipers EJ, Bruno MJ. Improving the quality of pretreatment staging in patients with esophageal carcinoma - a fast track study. Acta Oncol 2012; 51:362-7. [PMID: 22023087 DOI: 10.3109/0284186x.2011.626449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Current guidelines for esophageal cancer recommend series of diagnostic investigations to determine pretreatment TNM stage. When investigations are done sequentially, diagnostic work-up time may be prolonged considerably. Aim of the study was to determine the feasibility and efficacy of a fast track staging strategy within five days after the first consultation. MATERIAL AND METHODS Between 2007 and 2010 all patients presenting with esophageal cancer at the Department of Gastroenterology in a tertiary referral center were prospectively analyzed. At Day 1 all patients underwent computed tomography (CT), endoscopic ultrasound (EUS) and ultrasonography of the neck (US). Results and treatment implications were discussed within a multidisciplinary meeting. This fast track strategy was considered completed successfully if pre-treatment TNM classification was achieved and therapy was proposed to the patient at the outpatient clinic at Day five. In those cases where staging period time was prolonged, the number and type of additional tests were documented including the ensuing time delay. RESULTS In 111 patients CT, EUS and US were performed in 100%, 88.3% and 97.3% respectively. A final TNM stage and treatment proposal was reached at Day 5 in 60% of the patients. Additional tests were diverse and mainly used to prove local irresectabilty or presence of distant metastasis. Multivariate analysis identified presence of lymphadenopathy (HR 0.25 p = 0.03) and metastasis (HR 0.27 p = 0.03) as significant predictors of not completing the staging period within five days. In 18% of patients overuse of at least one test occurred, most commonly because CT already revealed distant metastasis. CONCLUSION Employment of a fast track five day staging strategy in patients with esophageal carcinoma is feasible. Definite TNM stage and treatment proposal can be achieved in 60% of cases, but comes at the expense of test overuse in about one fifth of patients.
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Affiliation(s)
- Paul Didden
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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31
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Van Heel NCM, Haringsma J, Spaander MCW, Didden P, Bruno MJ, Kuipers EJ. Esophageal stents for the palliation of malignant dysphagia and fistula recurrence after esophagectomy. Gastrointest Endosc 2010; 72:249-54. [PMID: 20537639 DOI: 10.1016/j.gie.2010.01.070] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Accepted: 01/28/2010] [Indexed: 01/12/2023]
Abstract
BACKGROUND Despite advances in staging methods, surgical techniques, and adjuvant treatment, recurrent cancer after esophagectomy is a major cause of morbidity and mortality. OBJECTIVE Our purpose was to investigate the safety and efficacy of a self-expandable metal stent (SEMS) in patients with dysphagia or fistula caused by recurrent cancer after esophagectomy. DESIGN Prospective, observational study with standardized treatment and follow-up. SETTING Single university center. PATIENTS In 81 patients with recurrent cancer after previous surgical esophagectomy, 100 esophageal SEMSs were inserted for dysphagia (n = 66) or fistula formation (n = 15). INTERVENTIONS Stent placement. MAIN OUTCOME MEASUREMENTS Technical and functional outcome, complications, and survival. RESULTS The SEMSs restored luminal patency in 65 (98%) of 66 patients and sealed malignant fistulae in 14 (93%) of 15 patients. Stent dysfunction occurred in 24 (30%) of 81 patients. They all were successfully managed by subsequent endoscopic intervention. After stent placement, a total of 16 complications were observed. Major complications occurred in 9 (11%) of 81 patients, mild complications occurred in 7 (9%) of 81 patients. The overall 30-day mortality rate after stent insertion was 25%. Progression of the disease resulted in death after a median interval of 70 days (range 1 day to 91 months). LIMITATIONS Nonrandomized design. CONCLUSIONS SEMS placement in recurrent esophageal cancer after surgical resection offers adequate palliation by relieving dysphagia and sealing off esophageal respiratory fistulae. Therefore, in these patients who have a relatively short life expectancy, SEMS placement should be considered the treatment of choice.
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Affiliation(s)
- Nicoline C M Van Heel
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
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Rolleman EJ, Hoorn EJ, Didden P, Zietse R. Guilty as charged: unmeasured urinary anions in a case of pyroglutamic acidosis. Neth J Med 2008; 66:351-353. [PMID: 18809984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
A patient developed an unexplained metabolic acidosis with the characteristics of renal tubular acidosis. By correcting the serum anion gap for hypoalbuminaemia and analysing the urinary anions and cations, the presence of unmeasured anions was revealed. The diagnosis of pyroglutamic acidosis, caused by a combination of flucloxacillin and acetaminophen, was established. Strategies for solving complex cases of metabolic acidosis are discussed.
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Affiliation(s)
- E J Rolleman
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
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Abstract
BACKGROUND Octreotide therapy is effective in controlling severe dumping symptoms during short-term follow-up but little is known about long-term results. AIM To report on the long-term results of patients with severe dumping syndrome treated at the Leiden University Medical Center with subcutaneous or depot intramuscular (long-acting release) octreotide. METHODS Follow-up of 34 patients with severe dumping syndrome refractory to other therapeutic measures treated between 1987 and 2005 with octreotide subcutaneous/long-acting release. At regular intervals symptoms, quality of life, weight, faecal fat excretion and gallstone formation were evaluated. RESULTS All patients had excellent initial relief of symptoms during octreotide subcutaneous therapy. However, during follow-up 16 patients stopped therapy because of side effects (n = 9) or loss of efficacy (n = 7). Four patients died. Fourteen patients (41%) remain using octreotide (follow-up 93 +/- 15 months), seven are on octreotide subcutaneous and seven on octreotide long-acting release. Patients with severe dumping (both early and late) do better on subcutaneous than long-acting release despite the inconvenience of frequent injections. Dumping symptoms are reduced by 50% even in long-term users. Body weight continues to increase during therapy despite more pronounced steatorrhoea. CONCLUSION The long-term the efficacy of octreotide is much less favourable compared with short-term treatment.
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Affiliation(s)
- P Didden
- Department of Gastroenterology-Hepatology, Leiden University Medical Center, Leiden, the Netherlands
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