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Selvanderan SP, Lam E, Shahidi N. Endohepatology: Arrival at the frontier of interventional endosonography. World J Gastroenterol 2024; 30:2397-2401. [PMID: 38764768 PMCID: PMC11099394 DOI: 10.3748/wjg.v30.i18.2397] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/16/2024] [Accepted: 04/19/2024] [Indexed: 05/11/2024] Open
Abstract
Endohepatology describes the emerging field where diagnostic and therapeutic endoscopic ultrasound (EUS) are used for the diagnosis and management of liver disease and its sequelae. In this editorial we comment on the article by Gadour et al. The spectrum of EUS-guided procedures includes liver parenchymal and lesional biopsy, abscess drainage, treatment of focal liver lesions, diagnosis of portal hypertension and management of gastric varices. The data suggest that the application of EUS to hepatology is technically feasible and safe, heralding the arrival at a new frontier for EUS. More data, specifically randomised trials comparing EUS to interventional radiology techniques, and continued partnership between endoscopy and hepatology are required to see this field establish itself outside expert tertiary centres.
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Affiliation(s)
- Shane P Selvanderan
- Department of Medicine, University of British Columbia, Vancouver V6Z 1Y6, BC, Canada
| | - Eric Lam
- Department of Medicine, University of British Columbia, Vancouver V6Z 1Y6, BC, Canada
| | - Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver V6Z 1Y6, BC, Canada
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Kim HJ, Zhao B, Shahidi N, Lam ECS. Peroral endoscopic myotomy in the presence of small esophageal varices. VideoGIE 2024; 9:221-223. [PMID: 38766394 PMCID: PMC11099197 DOI: 10.1016/j.vgie.2024.02.004] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Video 1XXX.
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Affiliation(s)
- Hyun Jae Kim
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Gastroenterology, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Billy Zhao
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Gastroenterology, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Eric C S Lam
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Gastroenterology, St. Paul's Hospital, Vancouver, British Columbia, Canada
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Leddin D, Singh H, Armstrong D, Cheyne K, Galts C, Igoe J, Leontiadis G, McGrath J, Pray C, Sadowski D, Shahidi N, Sinclair P, Tse F, Yanofsky R. The Canadian Association of Gastroenterology's New Climate Change Committee. J Can Assoc Gastroenterol 2024; 7:135-136. [PMID: 38596799 PMCID: PMC10999766 DOI: 10.1093/jcag/gwae006] [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: 04/11/2024] Open
Affiliation(s)
- Desmond Leddin
- Division of Digestive Care & Endoscopy, Department of Medicine, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | - Harminder Singh
- Section of Gastroenterology, Deparment of Internal Medicine, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
| | - David Armstrong
- Division of Gastroenterology, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Kelsey Cheyne
- Canadian Digestive Health Foundation, Oakville, ON L6M 4J2, Canada
| | - Ciaran Galts
- Division of Gastroenterology, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - John Igoe
- Division of Digestive Care & Endoscopy, Department of Medicine, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | | | - Jerry McGrath
- Department of Medicine, Memorial University, St. John’s, NL A1B 3V6, Canada
| | - Cara Pray
- Division of Gastroenterology, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Daniel Sadowski
- Department of Medicine, University of Alberta, Edmonton, AB T6G 2G3, Canada
| | - Neal Shahidi
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
| | | | - Frances Tse
- Division of Gastroenterology, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Russell Yanofsky
- Division of Gastroenterology, University of Toronto, Toronto, ON M5S 1A1, Canada
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Tate DJ, Vosko S, Bar-Yishay I, Desomer L, Shahidi N, Sidhu M, McLeod D, Bourke MJ. Incomplete Mucosal Layer Excision during Endoscopic Mucosal Resection: a potential source of recurrent adenoma. Gastrointest Endosc 2024:S0016-5107(24)00050-6. [PMID: 38280532 DOI: 10.1016/j.gie.2024.01.030] [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] [Received: 11/07/2023] [Revised: 12/29/2023] [Accepted: 01/22/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND AND AIMS Residual or recurrent adenoma detected during surveillance (RRA) is the major limitation of endoscopic mucosal resection (EMR). The pathogenesis of RRA is unknown although thermal ablation of the post-EMR defect (PED) margin reduces RRA. We aimed to identify a feature within the PED which could be associated with RRA. METHODS Between 1/2017 and 7/2020 detailed prospective procedural data on all EMR procedures performed at a single centre were retrospectively analysed. At the completion of EMR the PED was systematically examined for features of incomplete mucosal layer excision (IME). This was defined as a demarcated area within the PED bordered by a white electrocautery ring, containing endoscopically identifiable features suggesting incomplete resection of the mucosa including lacy capillaries and/or visible fibres of the muscularis mucosae. Areas of IME were re-injected and re-excised by snare and submitted separately for blinded specialist gastrointestinal pathologist review. RESULTS EMR was performed for 508 large non-pedunculated colorectal polyps (LNPCPs) (median size 35mm). In 10 PED (2.0%) an area of IME was identified and excised. Histopathological examination of areas of suspected IME demonstrated muscularis mucosae in 9/10 (90%), residual lamina propria in 9/10 (90.0%) and residual adenoma in 5/10 (50.0%). No RRA was detected during follow-up after re-excision of IME. CONCLUSION We report the novel finding of IME within the PED after EMR of LNPCPs. IME may contain microscopic residual adenoma and therefore is a risk for RRA during follow-up. After completion of EMR the PED should be carefully evaluated and if IME is found it should be excised.
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Affiliation(s)
- David J Tate
- Westmead Hospital, Gastroenterology and Hepatology (Sydney, NSW, Australia); University of Sydney, Medical School (Westmead, New South Wales, Australia); Faculty of Health Sciences, University of Ghent (Ghent, Belgium)
| | - Sergei Vosko
- Westmead Hospital, Gastroenterology and Hepatology (Sydney, NSW, Australia)
| | - Iddo Bar-Yishay
- Westmead Hospital, Gastroenterology and Hepatology (Sydney, NSW, Australia)
| | - Lobke Desomer
- Westmead Hospital, Gastroenterology and Hepatology (Sydney, NSW, Australia); AZ Delta Hospital, Roeselare (Roeselare, Belgium)
| | - Neal Shahidi
- Westmead Hospital, Gastroenterology and Hepatology (Sydney, NSW, Australia)
| | - Mayenaaz Sidhu
- Westmead Hospital, Gastroenterology and Hepatology (Sydney, NSW, Australia)
| | - Duncan McLeod
- ICPMR, Department of Pathology (Sydney, New South Wales, Australia)
| | - Michael J Bourke
- Westmead Hospital, Gastroenterology and Hepatology (Sydney, NSW, Australia); University of Sydney, Medical School (Westmead, New South Wales, Australia).
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Gupta S, Kurup R, Shahidi N, Vosko S, McKay O, Zahid S, Whitfield A, Lee EY, Williams SJ, Burgess NG, Bourke MJ. Safety and efficacy of physician-administered balanced-sedation for the endoscopic mucosal resection of large non-pedunculated colorectal polyps. Endosc Int Open 2024; 12:E1-E10. [PMID: 38188923 PMCID: PMC10769574 DOI: 10.1055/a-2180-8880] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 08/17/2023] [Indexed: 01/09/2024] Open
Abstract
Background and study aims Because of concerns about peri-procedural adverse events (AEs), guidelines recommend anesthetist-managed sedation (AMS) for long and complex endoscopic procedures. The safety and efficacy of physician-administered balanced sedation (PA-BS) for endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (LNPCPs) ≥20 mm is unknown. Patients and methods We compared PA-BS with AMS in a retrospective study of prospectively collected data from consecutive patients referred for management of LNPCPs (NCT01368289; NCT02000141). A per-patient propensity analysis was performed following a 1:2 nearest-neighbor (Greedy-type) match, based on age, gender, Charlson comorbidity index, and lesion size. The primary outcome was any peri-procedural AE, which included hypotension, hypertension, tachycardia, bradycardia, hypoxia, and new arrhythmia. Secondary outcomes were unplanned admissions, 28-day re-presentation, technical success, and recurrence. Results Between January 2016 and June 2020, 700 patients underwent EMR for LNPCPs, of whom 638 received PA-BS. Among them, the median age was 70 years (interquartile range [IQR] 62-76 years), size 35 mm (IQR 25-45 mm), and duration 35 minutes (IQR 25-60 minutes). Peri-procedural AEs occurred in 149 (23.4%), most commonly bradycardia (116; 18.2%). Only five (0.8%) required an unplanned sedation-related admission due to AEs (2 hypotension, 1 arrhythmia, 1 bradycardia, 1 hypoxia), with a median inpatient stay of 1 day (IQR 1-3 days). After propensity-score matching, there were no differences between PA-BS and AMS in peri-procedural AEs, unplanned admissions, 28-day re-presentation rates, technical success or recurrence. Conclusions Physician-administered balanced sedation for the EMR of LNPCPs is safe. Peri-procedural AEs are infrequent, transient, rarely require admission (<1%), and are experienced in similar frequencies to those receiving anesthetist-managed sedation.
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Affiliation(s)
- Sunil Gupta
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
| | - Rajiv Kurup
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
| | - Neal Shahidi
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
- Gastroenterology and Hepatology, The University of British Columbia Faculty of Medicine, Vancouver, Canada
| | - Sergei Vosko
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
| | - Owen McKay
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
| | - Simmi Zahid
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
| | - Anthony Whitfield
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
| | - Eric Y. Lee
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
| | | | - Nicholas Graeme Burgess
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
| | - Michael J. Bourke
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, Australia
- Medicine, The University of Sydney Westmead Clinical School, Westmead, Australia
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Gupta S, Vosko S, Shahidi N, O'Sullivan T, Cronin O, Whitfield A, Kurup R, Sidhu M, Lee EYT, Williams SJ, Burgess NG, Bourke MJ. Endoscopic resection-related colorectal strictures: risk factors, management, and long-term outcomes. Endoscopy 2023; 55:1010-1018. [PMID: 37279786 DOI: 10.1055/a-2106-6494] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Colorectal strictures related to endoscopic resection (ER) of large nonpedunculated colorectal polyps (LNPCPs) may be problematic. Data on prevalence, risk factors, and management are limited. We report a prospective study of colorectal strictures following ER and describe our approach to management. METHODS We analyzed prospectively collected data over 150 months, until June 2021, for patients who underwent ER for LNPCPs ≥ 40 mm. The ER defect size was graded as < 60 %, 60 %-89 %, or ≥ 90 % of the luminal circumference. Strictures were considered "severe" if patients experienced obstructive symptoms, "moderate" if an adult colonoscope could not pass the stenosis, or "mild" if there was resistance on successful passage. Primary outcomes included stricture prevalence, risk factors, and management. RESULTS 916 LNPCPs ≥ 40 mm in 916 patients were included (median age 69 years, interquartile range 61-76 years, male sex 484 [52.8 %]). The primary resection modality was endoscopic mucosal resection in 859 (93.8 %). Risk of stricture formation with an ER defect ≥ 90 %, 60 %-89 %, and < 60 % was 74.2 % (23/31), 25.0 % (22/88), and 0.8 % (6 /797), respectively. Severe strictures only occurred with ER defects ≥ 90 % (22.6 %, 7/31). Defects < 60 % conferred low risk of only mild strictures (0.8 %, 6/797). Severe strictures required earlier (median 0.9 vs. 4.9 months; P = 0.01) and more frequent (median 3 vs. 2; P = 0.02) balloon dilations than moderate strictures. CONCLUSION Most patients with ER defects ≥ 90 % of luminal circumference developed strictures, many of which were severe and required early balloon dilation. There was minimal risk with ER defects < 60 %.
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Affiliation(s)
- Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Timothy O'Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Rajiv Kurup
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
- University of Sydney, Westmead Clinical School, Sydney, Australia
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Tate DJ, Desomer L, Argenziano ME, Mahajan N, Sidhu M, Vosko S, Shahidi N, Lee E, Williams SJ, Burgess NG, Bourke MJ. Treatment of adenoma recurrence after endoscopic mucosal resection. Gut 2023; 72:1875-1886. [PMID: 37414440 DOI: 10.1136/gutjnl-2023-330300] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 05/22/2023] [Accepted: 05/29/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE Residual or recurrent adenoma (RRA) after endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (LNPCPs) of ≥20 mm is a major limitation. Data on outcomes of the endoscopic treatment of recurrence are scarce, and no evidence-based standard exists. We investigated the efficacy of endoscopic retreatment over time in a large prospective cohort. DESIGN Over 139 months, detailed morphological and histological data on consecutive RRA detected after EMR for single LNPCPs at one tertiary endoscopy centre were prospectively recorded during structured surveillance colonoscopy. Endoscopic retreatment was performed on cases with evidence of RRA and was performed predominantly using hot snare resection, cold avulsion forceps with adjuvant snare tip soft coagulation or a combination of the two. RESULTS 213 (14.6%) patients had RRA (168 (78.9%) at first surveillance and 45 (21.1%) thereafter). RRA was commonly 2.5-5.0 mm (48.0%) and unifocal (78.7%). Of 202 (94.8%) cases which had macroscopic evidence of RRA, 194 (96.0%) underwent successful endoscopic therapy and 161 (83.4%) had a subsequent follow-up colonoscopy. Of the latter, endoscopic therapy of recurrence was successful in 149 (92.5%) of 161 in the per-protocol analysis, and 149 (73.8%) of 202 in the intention-to-treat analysis, with a mean of 1.15 (SD 0.36) retreatment sessions. No adverse events were directly attributable to endoscopic therapy. Further RRA after endoscopic therapy was endoscopically treatable in most cases. Overall, only 9 (4.2%, 95% CI 2.2% to 7.8%) of 213 patients with RRA required surgery.Thus 159 (98.8%, 95% CI 95.1% to 99.8%) of 161 cases with initially successful endoscopic treatment of RRA and follow-up remained surgery-free for a median of 13 months (IQR 25.0) of follow-up. CONCLUSIONS RRA after EMR of LNPCPs can be effectively treated using simple endoscopic techniques with long-term adenoma remission of >90%; only 16% required retreatment. Therefore, more technically complex, morbid and resource-intensive endoscopic or surgical techniques are required only in selected cases. TRIAL REGISTRATION NUMBERS NCT01368289 and NCT02000141.
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Affiliation(s)
- David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Gent, Belgium
- Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Lobke Desomer
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Maria Eva Argenziano
- Department of Gastroenterology and Hepatology, University Hospital of Ghent, Gent, Belgium
| | - Neha Mahajan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Alshihry I, Tomaszewski M, Vosko S, Bourke MJ, Shahidi N. Once is by chance; twice is a trend: a recurring finding within the postresection defect. Gastrointest Endosc 2023; 97:803-804. [PMID: 36535379 DOI: 10.1016/j.gie.2022.12.011] [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] [Received: 04/26/2022] [Revised: 08/26/2022] [Accepted: 12/13/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Iyad Alshihry
- Division of Gastroenterology, St. Paul's Hospital, Vancouver, British Columbia, Canada; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marcel Tomaszewski
- Division of Gastroenterology, St. Paul's Hospital, Vancouver, British Columbia, Canada; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sergei Vosko
- Shamir Medical Center, Gastroenterology and Liver Diseases Institute, Be'er Ya'akov, Israel
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Neal Shahidi
- Division of Gastroenterology, St. Paul's Hospital, Vancouver, British Columbia, Canada; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Tam L, Akhtar D, Hill E, Jiang S, Ghuman A, Xiong W, Shahidi N. A97 LARGE NON-PEDUNCULATED COLONIC POLYP (LNPCP) OUTCOMES REFERRED FOR ENDOSCOPIC RESECTION IN BRITISH COLUMBIA: A QUALITY ASSURANCE INITIATIVE. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991281 DOI: 10.1093/jcag/gwac036.097] [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: 03/09/2023] Open
Abstract
Background Endoscopic resection techniques have become the primary treatment strategy for the vast majority of large (≥ 20mm) non-pedunculated colonic polyps (LNPCPs). Despite this, surgery is still commonly performed with evidence suggesting an increasing trend over time. There is limited Canadian data confirming the effectiveness and safety of an endoscopic management strategy for LNPCPs. Purpose To investigate clinical outcomes of patients referred for endoscopic management of a LNPCP. Method Retrospective single-centre analysis of patients referred to a single endoscopist for the management of LNPCPs within a tertiary referral practice. LNPCPs were further subdivided into non-complicated (NC-LNPCP) or complicated (C-LNPCP) defined as those involving the ileocecal valve, appendiceal orifice, circumferential or previously attempted. Performance outcomes were evaluated by the frequencies of technical success (removal of all polypoid tissue during index procedure) and need for colorectal surgery. Safety was evaluated by the frequencies of clinically significant intraprocedural bleeding (CSIPB), clinically significant post-endoscopic resection bleeding (CSPEB), intra-procedural perforation and delayed perforation. Recurrence (either endoscopic or histologic) was evaluated at first surveillance colonoscopy (SC1). Continuous variables were summarized using median (IQR). Categorical variables were summarized as frequencies (%). To test for association between categorical variables, the Pearson χ2 or the Fisher exact test were used, where appropriate. For continuous variables, the Mann-Whitney U test was used. A probability (p) value of <0.05 was considered statistically significant. Result(s) Between January 2021 to March 2022, 263 LNPCP were referred for endoscopic resection and 41 LNPCP were excluded (23 pedunculated, 14 optical evaluation suggestive of deeply invasive cancer, 4 other). 222 LNPCP (188 NC-LNPCP, 34 C-LNPCP) underwent endoscopic resection. Median size was 25mm (IQR 20-30mm) with the majority undergoing cold snare resection (115, 51.8%). Polyposis (Adenomatous or serrated) was present in 23 (12.6%) cases respectively. Technical success was 97.3%. Cancer was present in 5 (2%). Clinically significant bleeding (CSPEB) occurred in 2.7%, DMI IV in 1.8% and there were no delayed perforations. Recurrence occurred in 4 (3.5%) at SC1 and 11 (5%) required surgery due to technical failure, submucosal invasion on pathology and clinically significant bleeding. Image ![]()
Conclusion(s) Endoscopic resection as the primary treatment strategy for LNPCPs offers a safe and effective alternative to surgery in British Columbia. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared
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Affiliation(s)
| | | | | | | | | | - W Xiong
- Pathology and Laboratory Medicine, UBC, Vancouver, Canada
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Arif AA, Donaldson K, Qian H, Lam E, Shahidi N. A122 MINIMALLY INVASIVE ENDOSCOPIC RESECTION TECHNIQUES FOR ANORECTAL JUNCTION NEOPLASIA: A SYSTEMATIC REVIEW AND META-ANALYSIS. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991280 DOI: 10.1093/jcag/gwac036.122] [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: 03/09/2023] Open
Abstract
Background The management of neoplastic lesions at the anorectal junction remains debated. Endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) have emerged as the primary endoscopic modalities of choice. Purpose We sought to compare the performance of ESD and EMR in resection of anorectal neoplasia. Method Two authors independently searched MEDLINE, EMBASE and Cochrane Libraries (Jan 2000 – Aug 2021) for citations evaluating the performance of endoscopic resection techniques (ESD, EMR) for lesions involving the anorectal junction (defined as within 20mm of the dentate line). The frequencies and 95% confidence intervals (95% CI) of technical success (complete removal of all neoplastic tissue at index procedure), clinically significant post-endoscopic resection bleeding (CSPEB), delayed perforation, recurrence and referral to surgery were assessed using random-effects modelling. Result(s) We included 11 studies (total 563 patients: 414 ESD, 149 EMR) of which nine were ESD and two were EMR studies. Technical success was achieved in 97.2% overall (95% CI 94.8%-98.5%, ESD 97.5% and EMR range 93.9%-98.0%). Clinically significant post-endoscopic resection bleeding occurred in 4.3% (95% CI 1.6%-11.1%, ESD 3.0% and EMR range 8.2%-11.0%). Delayed perforation was not identified. Recurrence at first screening colonoscopy occurred in 4.8% (95% CI 1.9%-11.7%, ESD 3.0% and EMR range 15.4%-18.4%). Referral to surgery for any reason occurred in 5.9% (95% CI 4.3%-8.0%, ESD 6.9%, EMR range 2.0%-3.0%). Conclusion(s) ESD and EMR demonstrate high frequencies of technical success but may have different rates of adverse events and recurrence. More studies investigating lesions at the anorectal junction should be conducted including head-to-head analyses between ESD and EMR for low-risk anorectal junction neoplasia. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared
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Affiliation(s)
| | | | - H Qian
- Centre for Health Evaluation and Outcome Sciences
| | - E Lam
- University of British Columbia,St. Paul's Hospital , Vancouver, Canada
| | - N Shahidi
- University of British Columbia,St. Paul's Hospital , Vancouver, Canada
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Jiang SX, Xiong W, Shahidi N. A132 A CASE OF COLONIC MALAKOPLAKIA PRESENTING AS A LARGE CECAL MASS : NOT EVERY POLYP HAS TO LOOK LIKE A NAIL. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991152 DOI: 10.1093/jcag/gwac036.132] [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: 03/09/2023] Open
Abstract
Background Malakoplakia is a rare inflammatory condition, commonly affecting the genitourinary system of immunocompromised patients. Gastrointestinal malakoplakia has been reported in the literature, with previous endoscopic findings mimicking mass lesions. Purpose To describe a case of colonic malakoplakia after referral for endoscopic management of a large non-pedunculated colorectal polyp. Method Case report and review of the literature. Result(s) Case Report An 80-year-old male with chronic kidney disease and remote renal transplant on immunosuppressive therapy (mycophenolate mofetil, tacrolimus, prednisone) was referred for endoscopic resection for a large non-pedunculated colorectal polyp in the cecum. Original presenting symptoms included chronic diarrhea, iron deficiency anemia, and fecal immunochemical test (FIT) positivity. A repeat colonoscopy demonstrated a 40mm Paris 0-IIA plaque-like lesion in the cecum with optical features not in keeping with adenomatous or serrated histopathology. Biopsies were performed with histopathology demonstrating normal colonic mucosa with confluent sheets of histiocytes with concentrically layered cytoplasmic inclusions, in keeping with malakoplakia. Literature review Malakoplakia, Greek for “soft plaque”, is a rare inflammatory condition characterized by impaired dysfunction in macrophages leading to the accumulation of incompletely degraded bacteria in phagolysosomes. Histologically, this appears as concentrically layered cytoplasmic inclusions, comprising the pathognomonic Michaelis-Gutmann bodies. Many bacterial organisms have been implicated in the development of malakoplakia, with E. coli being the most common; specifically in immunocompromised patients, whether from immunosuppressive medications, immunodeficiency syndromes, or clinical conditions precluding effective immune function. Malakoplakia commonly presents as a mass-like lesion and has been found in all organs, most commonly in the genitourinary system. Diagnosis is made by biopsy and allows for appropriate treatment, which is most commonly a reduction in immunosuppressive therapy and antibiotic therapy. Image ![]()
Conclusion(s) Malakoplakia is rare but should be considered when a lesion with atypical optical evaluation features is found in immunocompromised individuals or those with recurrent infections. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared
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Affiliation(s)
| | | | - N Shahidi
- Gastroenterology, University of British Columbia, Vancouver, Canada
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12
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Jiang SX, Xiong W, Shahidi N. A138 SERRATED POLYPOSIS SYNDROME IN INFLAMMATORY BOWEL DISEASE: A SEQUELAE OF CHRONIC DISEASE ACTIVITY OR NEW WHO PHENOTYPE? J Can Assoc Gastroenterol 2023. [PMCID: PMC9991396 DOI: 10.1093/jcag/gwac036.138] [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: 03/09/2023] Open
Abstract
Background Serrated polyposis syndrome (SPS) is a growing health concern with up to 1 in 125 universal screening program participants meeting diagnostic criteria. Conversely, SPS in inflammatory bowel disease (IBD) is rarely described in the literature, despite the predisposition for serrated epithelial change and serrated polyps in this population. Purpose To describe a case of World Health Organization (WHO) criterion I SPS in a patient with IBD, and discuss the existing literature on this rare occurrence. Method Case report and review of the literature. Result(s) Case Report A 53-year-old female with ulcerative colitis (UC; Phenotype: Left-sided; Duration of disease: 40 years; Medical therapy: sulfasalazine) undergoing regular endoscopic surveillance was recently found to have multiple serrated-class lesions including 6 in the sigmoid colon ranging between 8-30mm in size; this included 3 sessile serrated lesions (SSLs) between 20-30mm removed by piecemeal cold snare resection without complication and 2 residual large SSLs for staged endoscopic resection. No endoscopic disease activity was appreciated (Mayo 0), with histopathology of the sigmoid colon and rectum demonstrating chronic inactive colitis. Literature Review From 2008 to 2021, there are eleven reported cases of SPS in IBD. Six patients had UC and most were in remission for several decades at the time of SPS diagnosis. Most SPS cases met WHO criteria and fit within described phenotypes. While the case above meets WHO criterion I for SPS, the presence of large distal lesions is atypical, raising the question of whether chronic disease activity contributed to the development of these serrated lesions, given the known predisposition for serrated epithelial change and serrated lesions in patients with colonic IBD. Image ![]()
Conclusion(s) SPS in patients with IBD is rare. Questions remain about the role of chronic disease activity contributing to the formation of serrated lesions, its clinical relevance, and optimal management strategy. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared
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Affiliation(s)
| | | | - N Shahidi
- Gastroenterology, University of British Columbia, Vancouver, Canada
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13
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Buttar J, Enns R, Lam E, Shahidi N. A120 ENDOSCOPIC CLOSURE TECHNIQUES FOLLOWING ACUTE IATROGENIC PERFORATION -- AN UPDATED SYSTEMATIC REVIEW. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991129 DOI: 10.1093/jcag/gwac036.120] [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: 03/09/2023] Open
Abstract
Background Iatrogenic perforation is arguably the most feared adverse event associated with endoscopy. Current American Society for Gastrointestinal Endoscopy (ASGE) and European Society of Gastroenterology Endoscopy (ESGE) guidelines recommend endoscopic closure as the first-line treatment strategy. Historically, this has been achieved using through-the-scope clips (TTSC). Given the emergence of alternative endoscopic closure techniques including over-the-scope clips (OTSC) and endoscopic suturing, we sought to provide an updated review of the literature. Purpose To review endoscopic closure techniques following iatrogenic perforation during screening or therapeutic endoscopy. Method Based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines, an electronic search of MEDLINE and EMBASE from June 1st, 1946 – Oct 10th, 2022 was performed. Inclusion criteria was limited to English full-text original citations, with case reports, and cohorts with < 3 patients excluded. Our primary objective was to assess complete defect closure after attempted endoscopic treatment. Outcomes were stratified by modality (TTSC, OTSC, endoscopic suturing) and chronologically based on a previous well received systematic review. Result(s) A total of 2549 citations were identified in our electronic search, of which 34 were included representing 830 perforations. Overall, successful endoscopic closure was achieved in 763 cases (91.9%). When stratified by endoscopic closure techniques, range estimates for successful endoscopic closure was 71% – 100%, 57% - 100%, and 100% for TTSC, OTSC and endoscopic suturing respectively. When stratifying chronologically, an improvement in TTSC closure was identified. Conclusion(s) Endoscopic defect closure, including TTSC, OTSC and endoscopic suturing, are effective in the management of iatrogenic perforations with increasing TTSC performance over time. It remains the primary treatment strategy for iatrogenic perforation. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared
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Affiliation(s)
| | | | - E Lam
- Adult Gastroenterology - Clinical Associate Professor, University of British Columbia, Vancouver, Canada
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14
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Ebigbo A, Mendel R, Scheppach MW, Probst A, Shahidi N, Prinz F, Fleischmann C, Römmele C, Goelder SK, Braun G, Rauber D, Rueckert T, de Souza LA, Papa J, Byrne M, Palm C, Messmann H. Vessel and tissue recognition during third-space endoscopy using a deep learning algorithm. Gut 2022; 71:2388-2390. [PMID: 36109151 PMCID: PMC9664130 DOI: 10.1136/gutjnl-2021-326470] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 06/29/2022] [Indexed: 01/26/2023]
Abstract
In this study, we aimed to develop an artificial intelligence clinical decision support solution to mitigate operator-dependent limitations during complex endoscopic procedures such as endoscopic submucosal dissection and peroral endoscopic myotomy, for example, bleeding and perforation. A DeepLabv3-based model was trained to delineate vessels, tissue structures and instruments on endoscopic still images from such procedures. The mean cross-validated Intersection over Union and Dice Score were 63% and 76%, respectively. Applied to standardised video clips from third-space endoscopic procedures, the algorithm showed a mean vessel detection rate of 85% with a false-positive rate of 0.75/min. These performance statistics suggest a potential clinical benefit for procedure safety, time and also training.
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Affiliation(s)
- Alanna Ebigbo
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Robert Mendel
- Regensburg Medical Image Computing (ReMIC), Ostbayerische Technische Hochschule Regensburg, Regensburg, Germany
| | - Markus W Scheppach
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Andreas Probst
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Friederike Prinz
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Carola Fleischmann
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Christoph Römmele
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | | | - Georg Braun
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | - David Rauber
- Regensburg Medical Image Computing (ReMIC), Ostbayerische Technische Hochschule Regensburg, Regensburg, Germany
| | - Tobias Rueckert
- Regensburg Medical Image Computing (ReMIC), Ostbayerische Technische Hochschule Regensburg, Regensburg, Germany
| | - Luis A de Souza
- Department of Computing, Federal University of São Carlos, São Carlos, Brazil
| | - Joao Papa
- Department of Computing, São Paulo State University, Botucatu, Brazil
| | - Michael Byrne
- Vancouver General Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Christoph Palm
- Regensburg Medical Image Computing (ReMIC), Ostbayerische Technische Hochschule Regensburg, Regensburg, Germany
| | - Helmut Messmann
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
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15
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Vosko S, Shahidi N, Gupta S, van Hattem WA, Bourke MJ. 'Fish-eye' polypectomy defect: a new sign during endoscopic mucosal resection? Gut 2022; 71:2413-2488. [PMID: 34376516 DOI: 10.1136/gutjnl-2020-323858] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 07/23/2021] [Indexed: 12/08/2022]
Affiliation(s)
- Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia.,Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia .,Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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16
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Cronin O, Sidhu M, Shahidi N, Gupta S, O'Sullivan T, Whitfield A, Wang H, Kumar P, Hourigan LF, Byth K, Burgess NG, Bourke MJ. Comparison of the morphology and histopathology of large nonpedunculated colorectal polyps in the rectum and colon: implications for endoscopic treatment. Gastrointest Endosc 2022; 96:118-124. [PMID: 35219724 DOI: 10.1016/j.gie.2022.02.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/15/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The risk of cancer in large nonpedunculated colorectal polyps ≥20 mm (LNPCPs) in the rectum relative to the remainder of the colon is unknown. We aimed to describe differences between rectal and colonic LNPCPs to better inform treatment decisions. METHODS Patients with LNPCPs referred to tertiary centers for endoscopic resection within a prospective, multicenter, observational cohort were evaluated. Data recorded were participant demographics, LNPCP location, morphology, resection modality, and histopathologic data. Multiple logistic regression analysis was used to identify those variables independently associated with rectal versus nonrectal location in the colon. RESULTS Patients with LNPCPs referred for endoscopic resection between July 2008 and July 2021 were included. Rectal LNPCPs (n = 618) were larger (median size, 40 mm vs 30 mm; P < .001) and more likely to be granular (79% vs 50%, P < .001) with a nodular component (53% vs 17%, P < .001) compared with nonrectal LNPCPs (n = 2787). Rectal LNPCPs were more likely to have tubulovillous histopathology (72% vs 47%, P < .001) and contain cancer (15% vs 6%, P < .001). After adjusting for the other features independently associated with location, cancer was more common in the rectum compared with the colon (odds ratio, 1.77; 95% confidence interval, 1.25-2.53). CONCLUSIONS This study suggests that compared with LNPCPs in the rest of the colon, rectal LNPCPs are more likely to be larger and contain more advanced pathology. These findings have implications for curative endoscopic resection techniques particularly where early cancer is present. (Clinical trial registration numbers: NCT01368289 and NCT02000141.).
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Affiliation(s)
- Oliver Cronin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia; Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, School of Medicine, University of Queensland, Brisbane, Queensland, Australia; Gallipoli Medical Research Foundation, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Timothy O'Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Hunter Wang
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Puja Kumar
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, School of Medicine, University of Queensland, Brisbane, Queensland, Australia; Gallipoli Medical Research Foundation, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Karen Byth
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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17
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Shahidi N, Rex DK. Defining Conventional Endoscopic Mucosal Resection in 2021: A Burning Issue. Gastroenterology 2022; 162:1776-1777. [PMID: 34499914 DOI: 10.1053/j.gastro.2021.09.008] [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] [Received: 08/24/2021] [Accepted: 09/02/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Neal Shahidi
- Division of Gastroenterology, St. Paul's Hospital, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Douglas K Rex
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana
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18
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Jain A, Bedi H, Bourke MJ, Shahidi N. Measure twice, cut once: an unexpected finding within the postresection defect. Gastrointest Endosc 2022; 95:808-809. [PMID: 34863806 DOI: 10.1016/j.gie.2021.11.027] [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] [Received: 08/17/2021] [Accepted: 11/29/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Avni Jain
- Division of Gastroenterology, St. Paul's Hospital, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Harjot Bedi
- Division of Gastroenterology, St. Paul's Hospital, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Neal Shahidi
- Division of Gastroenterology, St. Paul's Hospital, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada; University of Sydney, Westmead Clinical School, Sydney, Australia
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19
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Sidhu M, Shahidi N, Vosko S, van Hattem WA, Tate DJ, Bourke MJ. Incremental benefit of dye-based chromoendoscopy to predict the risk of submucosal invasive cancer in large nonpedunculated colorectal polyps. Gastrointest Endosc 2022; 95:527-534.e2. [PMID: 34875258 DOI: 10.1016/j.gie.2021.11.032] [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] [Received: 07/21/2021] [Accepted: 11/13/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Detailed lesion assessment of large nonpedunculated colorectal polyps (LNPCPs; ≥20 mm) can help predict the risk of submucosal invasive cancer (SMIC). Traditionally this has required the use of dye-based chromoendoscopy (DBC). We sought to assess the accuracy and incremental benefit of DBC in addition to high-definition white-light imaging (HDWLI) and virtual chromoendoscopy (VCE) for the prediction of SMIC within LNPCPs. METHODS A prospective observational study of consecutive LNPCPs at a single tertiary referral center was performed. Before resection all lesions were assessed for the presence of a demarcated area (DA), defined as an area of disordered pit or microvascular pattern, by 2 trained endoscopists before and after DBC. Diagnostic performance characteristics were calculated with histology as the reference criterion standard, and overall agreement was calculated using the κ statistic. RESULTS Over 39 months to March 2021, 400 consecutive LNPCPs (median lesion size, 35 mm; interquartile range, 25-45) were analyzed. The overall rate of SMIC was 6.5%. Presence of a DA had an accuracy of 91% (95% confidence interval, 87.7-93.5) for SMIC, independent of the use of DBC. The rate of interobserver agreement for presence of a DA using HDWLI + VCE was very high (κ = .96) with no benefit gained by the addition of DBC. CONCLUSIONS The use of HDWLI and VCE is likely to be adequate for lesion assessment for the prediction of SMIC among LNPCPs. Further, the absence of a DA is strongly predictive for the absence of SMIC, independent to the use of DBC. (Clinical trial registration number: NCT03506321.).
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Affiliation(s)
- Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School, The University of Sydney, Sydney, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School, The University of Sydney, Sydney, Australia; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - David J Tate
- Westmead Clinical School, The University of Sydney, Sydney, Australia; Department of Gastroenterology and Hepatology, University Hospital of Gent, Gent, Belgium
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School, The University of Sydney, Sydney, Australia
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20
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Shahidi N, Gupta S, Whitfield A, Vosko S, McKay O, Cronin O, Zahid S, Burgess NG, Bourke MJ. Simple optical evaluation criteria reliably identify the post-endoscopic mucosal resection scar for benign large non-pedunculated colorectal polyps without tattoo placement. Endoscopy 2022; 54:173-177. [PMID: 33784758 DOI: 10.1055/a-1469-9917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 01/14/2023]
Abstract
BACKGROUND Recognition of the post-endoscopic mucosal resection (EMR) scar is critical for large (≥ 20 mm) non-pedunculated colorectal polyp (LNPCP) management. The utility of intraluminal tattooing to facilitate scar identification is unknown. METHODS We evaluated the ability of simple easy-to-use optical evaluation criteria to detect the post-EMR scar, with or without tattoo placement, in a prospective observational cohort of LNPCPs referred for endoscopic resection. The primary outcome was scar identification, further stratified by lesion size (20-39 mm, ≥ 40 mm) and histopathology (adenomatous, serrated). RESULTS 1023 LNPCPs underwent both successful EMR and first surveillance colonoscopy (median size 35 mm, IQR 30-50 mm); 124 (12.1 %) had an existing tattoo or a tattoo placed at the index EMR. The post-EMR scar was identified in 1020 patients (99.7 %). The presence of a tattoo did not affect scar identification (100.0 % vs. 99.7 %; P > 0.99). There was no difference for LNPCPs 20-39 mm, LNPCPs ≥ 40 mm, adenomatous LNPCPs, and serrated LNPCPs (all P > 0.99). CONCLUSIONS The post-EMR scar can be reliably identified with simple easy-to-use optical evaluation criteria, without the need for universal tattoo placement.
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Affiliation(s)
- Neal Shahidi
- Westmead Hospital, Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia.,University of Sydney, Westmead Clinical School, Sydney, Australia.,University of British Columbia, Department of Medicine, Vancouver, Canada
| | - Sunil Gupta
- Westmead Hospital, Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia.,University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Anthony Whitfield
- Westmead Hospital, Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Sergei Vosko
- Westmead Hospital, Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Owen McKay
- Westmead Hospital, Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Oliver Cronin
- Westmead Hospital, Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia.,University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Simmi Zahid
- Westmead Hospital, Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia.,University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Nicholas G Burgess
- Westmead Hospital, Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia.,University of Sydney, Westmead Clinical School, Sydney, Australia
| | - Michael J Bourke
- Westmead Hospital, Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia.,University of Sydney, Westmead Clinical School, Sydney, Australia
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21
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Spadaccini M, Bourke MJ, Maselli R, Pioche M, Bhandari P, Jacques J, Haji A, Yang D, Albéniz E, Kaminski MF, Messmann H, Herreros de Tejada A, Sferrazza S, Pekarek B, Rivory J, Geyl S, Gulati S, Draganov P, Shahidi N, Hossain E, Fleischmann C, Vespa E, Iannone A, Alkandari A, Hassan C, Repici A. Clinical outcome of non-curative endoscopic submucosal dissection for early colorectal cancer. Gut 2022; 71:gutjnl-2020-323897. [PMID: 35058275 DOI: 10.1136/gutjnl-2020-323897] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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] [Received: 12/17/2020] [Accepted: 01/08/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Endoscopic submucosal dissection (ESD) in a curative intent for submucosa-invasive early (T1) colorectal cancers (T1-CRCs) often leads to subsequent surgical resection in case of histologic parameters indicating higher risk of nodal involvement. In some cases, however, the expected benefit may be offset by the surgical risks, suggesting a more conservative approach. DESIGN Retrospective analysis of consecutive patients with T1-CRC who underwent ESD at 13 centres ending inclusion in 2019 (n=3373). Cases with high risk of nodal involvement (non-curative ESD: G3, submucosal invasion>1000 µm, lymphovascular involvement, budding or incomplete resection/R1) were analysed if follow-up data (endoscopy/imaging) were available, regardless of the postendoscopic management (follow-up vs surgery) selected by the multidisciplinary teams in these institutions. Comorbidities were classified according to Charlson Comorbidity Index (CCI). Outcomes were disease recurrence, death and disease-related death rates in the two groups. Rate of residual disease (RD) at both the previous resection site and regional lymph nodes was assessed in the surgical cases as well as from follow-up in the follow-up group. RESULTS Of 604 patients treated by colorectal ESD for submucosally invasive cancer, 207 non-curative resections (34.3%) were included (138 male; mean age 67.6±10.9 years); in 65.2% of cases, no complete resection was achieved (R1). Of the 207 cases, 60.9% (n=126; median CCI: 3; IQR: 2-4) underwent surgical treatment with RD in 19.8% (25/126), while 39.1% (n=81, median CCI: 5; IQR: 4-6) were followed up by endoscopy in all cases. Patients in the follow-up group had a higher overall mortality (HR=3.95) due to non-CRC causes (n=9, mean survival after ESD 23.7±13.7 months). During this follow-up time, tumour recurrence and disease-specific survival rates were not different between the groups (median follow-up 30 months; range: 6-105). CONCLUSION Following ESD for a lesion at high risk of RD, follow-up only may be a reasonable choice in patients at high risk for surgery. Also, endoscopic resection quality should be improved. TRIAL REGISTRATION NUMBER NCT03987828.
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Affiliation(s)
- Marco Spadaccini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center -IRCCS-, Rozzano, Italy
| | - Michael J Bourke
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center -IRCCS-, Rozzano, Italy
| | - Marhieu Pioche
- Endoscopy unit, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | | | | | - Amyn Haji
- Endoscopy unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Dennis Yang
- Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Eduardo Albéniz
- Gastroenterology Department, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
| | - Michal Filip Kaminski
- Department of Gastroenterology, Hepatology and Oncology, Medical Centre fo Postgraduate Education, Warsaw, Poland
- Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre, Institute of Oncology, Warsaw, Poland
| | - Helmut Messmann
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Bayern, Germany
| | | | - Sandro Sferrazza
- Endoscopy unit, Ospedale di Trento, Trento, Trentino-Alto Adige, Italy
| | - Boris Pekarek
- University Hospital Bratislava, Bratislava, Slovakia
| | - Jerome Rivory
- Endoscopy unit, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Sophie Geyl
- Gastroenterology, Hospital Dupuytren, Limoges, France
| | - Shraddha Gulati
- Endoscopy unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Peter Draganov
- Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Neal Shahidi
- Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Ejaz Hossain
- Endoscopy unit, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Carola Fleischmann
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Bayern, Germany
| | - Edoardo Vespa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center -IRCCS-, Rozzano, Italy
| | - Andrea Iannone
- U.O. Gastroenterologia Universitaria, Policlinico di Bari, Bari, Italy
| | - Asma Alkandari
- Gastroenterology, Amiri Hospital, Kuwait City, Kuwait
- Gastroenterology, Queen Alexandra Hospital, Portsmouth, Hampshire, UK
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center -IRCCS-, Rozzano, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Endoscopy Unit, Humanitas Clinical and Research Center -IRCCS-, Rozzano, Italy
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22
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Gupta S, Sidhu M, Shahidi N, Vosko S, McKay O, Zahid S, Whitfield A, Byth K, Brown G, Lee EYT, Williams SJ, Burgess NG, Bourke MJ. Effect of prophylactic endoscopic clip placement on clinically significant post-endoscopic mucosal resection bleeding in the right colon: a single-centre, randomised controlled trial. Lancet Gastroenterol Hepatol 2021; 7:152-160. [PMID: 34801133 DOI: 10.1016/s2468-1253(21)00384-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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] [Received: 07/02/2021] [Revised: 10/10/2021] [Accepted: 10/11/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) is a cornerstone in the management of large (≥20 mm) non-pedunculated colorectal polyps. Clinically significant post-EMR bleeding occurs in 7% of cases and is most frequently encountered in the right colon. We aimed to assess the use of prophylactic clip closure in preventing clinically significant post-EMR bleeding within the right colon. METHODS We conducted a randomised controlled trial at a tertiary centre in Australia. Patients referred for the EMR of large non-pedunculated colorectal polyps in the right colon were eligible. Patients were randomly assigned (1:1) into the clip or control (no clip) group, using a computerised random-number generator. The primary endpoint was clinically significant post-EMR bleeding, defined as haematochezia necessitating emergency department presentation, hospitalisation, or re-intervention within 14 days post-EMR, which was analysed on the basis of intention-to-treat principles. The trial is registered with ClinicalTrials.gov, NCT02196649, and has been completed. FINDINGS Between Feb 4, 2016, and Dec 15, 2020, 231 patients were randomly assigned: 118 to the clip group and 113 to the control group. In the intention-to-treat analysis, clinically significant post-EMR bleeding was less frequent in the clip group than in the control group (four [3·4%] of 118 patients vs 12 [10·6%] of 113; p=0·031; absolute risk reduction 7·2% [95% CI 0·7-13·8]; number needed to treat 13·9). There were no differences between groups in adverse events, including delayed perforation (one [<1%] in the clip group vs one [<1%] in the control group) and post-EMR pain (four [3%] vs six [5%]). No deaths were reported. INTERPRETATION Prophylactic clip closure can be performed following the EMR of large non-pedunculated colorectal polyps of 20 mm or larger in the right colon to reduce the risk of clinically significant post-EMR bleeding. FUNDING None.
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Affiliation(s)
- Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Owen McKay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Simmi Zahid
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Karen Byth
- Western Sydney Local Health District Research and Education Network, Westmead Hospital, Sydney, NSW, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Gregor Brown
- Department of Gastroenterology and Hepatology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, VIC, Australia
| | - Eric Yong Tat Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Stephen John Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Nicholas Graeme Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Michael John Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, Sydney, NSW, Australia.
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23
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Vosko S, Shahidi N, Sidhu M, van Hattem WA, Bar-Yishay I, Schoeman S, Tate DJ, Hourigan LF, Singh R, Moss A, Byth K, Lee EYT, Burgess NG, Bourke MJ. Optical Evaluation for Predicting Cancer in Large Nonpedunculated Colorectal Polyps Is Accurate for Flat Lesions. Clin Gastroenterol Hepatol 2021; 19:2425-2434.e4. [PMID: 33992780 DOI: 10.1016/j.cgh.2021.05.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 04/04/2021] [Revised: 05/10/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The ability of optical evaluation to diagnose submucosal invasive cancer (SMIC) prior to endoscopic resection of large (≥20 mm) nonpedunculated colorectal polyps (LNPCPs) is critical to inform therapeutic decisions. Prior studies suggest that it is insufficiently accurate to detect SMIC. It is unknown whether lesion morphology influences optical evaluation performance. METHODS LNPCPs ≥20 mm referred for endoscopic resection within a prospective, multicenter, observational cohort were evaluated. Optical evaluation was performed prior to endoscopic resection with the optical prediction of SMIC based on established features (Kudo V pit pattern, depressed morphology, rigidity/fixation, ulceration). Optical evaluation performance outcomes were calculated. Outcomes were reported by dominant morphology: nodular (Paris 0-Is/0-IIa+Is) vs flat (Paris 0-IIa/0-IIb) morphology. RESULTS From July 2013 to July 2019, 1583 LNPCPs (median size 35 [interquartile range, 25-50] mm; 855 flat, 728 nodular) were assessed. SMIC was identified in 146 (9.2%; 95% confidence interval [CI], 7.9%-10.8%). Overall sensitivity and specificity were 67.1% (95% CI, 59.2%-74.2%) and 95.1% (95% CI, 93.9%-96.1%), respectively. The overall SMIC miss rate was 3.0% (95% CI, 2.3%-4.0%). Significant differences in sensitivity (90.9% vs 52.7%), specificity (96.3% vs 93.7%), and SMIC miss rate (0.6% vs 5.9%) between flat and nodular LNPCPs were identified (all P < .027). Multiple logistic regression identified size ≥40 mm (odds ratio [OR], 2.0; 95% CI, 1.0-3.8), rectosigmoid location (OR, 2.0; 95% CI, 1.1-3.7), and nodular morphology (OR, 7.2; 95% CI, 2.8-18.9) as predictors of missed SMIC (all P < .039). CONCLUSIONS Optical evaluation performance is dependent on lesion morphology. In the absence of features suggestive of SMIC, flat lesions can be presumed benign and be managed accordingly.
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Affiliation(s)
- Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Iddo Bar-Yishay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Scott Schoeman
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, School of Medicine University of Queensland, Brisbane, Queensland, Australia; Department of Gastroenterology, Greenslopes Private Hospital, Gallipoli Medical Research Foundation, Brisbane, Queensland, Australia
| | - Rajvinder Singh
- Department of Gastroenterology and Hepatology, Lyell McEwan Hospital, Adelaide, South Australia, Australia
| | - Alan Moss
- Department of Endoscopic Services, Western Health, Melbourne, Victoria, Australia
| | - Karen Byth
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia; WSLHD Research and Education Network, Westmead Hospital, Sydney, New South Wales, Australia
| | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.
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24
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Vosko S, Gupta S, Shahidi N, van Hattem WA, Zahid S, McKay O, Whitfield A, Sidhu M, Tate DJ, Lee EYT, Byth K, Williams SJ, Burgess N, Bourke MJ. Impact of technical innovations in EMR in the treatment of large nonpedunculated polyps involving the ileocecal valve (with video). Gastrointest Endosc 2021; 94:959-968.e2. [PMID: 33989645 DOI: 10.1016/j.gie.2021.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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] [Received: 01/10/2021] [Accepted: 05/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The endoscopic management of large nonpedunculated colorectal polyps involving the ileocecal valve (ICV-LNPCPs) remains challenging because of its unique anatomic features, with long-term outcomes inferior to LNPCPs not involving the ICV. We sought to evaluate the impact of technical innovations and advances in the EMR of ICV-LNPCPs. METHODS The performance of EMR for ICV-LNPCPs was retrospectively evaluated in a prospective observational cohort of LNPCPs ≥20 mm. Efficacy was measured by clinical success (removal of all polypoid tissue during index EMR and avoidance of surgery) and recurrence at first surveillance colonoscopy. Accounting for the adoption of technical innovations, comparisons were made between an historical cohort (September 2008 to April 2016) and contemporary cohort (May 2016 to October 2020). Safety was evaluated by documenting the frequencies of intraprocedural bleeding, delayed bleeding, deep mural injury, and delayed perforation. RESULTS Between September 2008 to October 2020, 142 ICV-LNPCPs were referred for EMR. Median ICV-LNPCP size was 35 mm (interquartile range, 25-50 mm). When comparing the contemporary (n = 66) and historical cohorts (n = 76) of ICV-LNPCPs, there were significant differences in clinical success (93.9% vs 77.6%, P = .006) and recurrence (4.6% vs 21.0%, P = .019). CONCLUSIONS With technical advances, ICV-LNPCPs can be effectively and safely managed by EMR, independent of lesion complexity. Most patients experience excellent outcomes and avoid surgery.
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Affiliation(s)
- Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Simmi Zahid
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Owen McKay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Anthony Whitfield
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | | | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Karen Byth
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia; WSLHD Research and Education Network, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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25
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van Hattem WA, Shahidi N, Vosko S, Hartley I, Britto K, Sidhu M, Bar-Yishay I, Schoeman S, Tate DJ, Byth K, Hewett DG, Pellisé M, Hourigan LF, Moss A, Tutticci N, Bourke MJ. Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods. Gut 2021; 70:1691-1697. [PMID: 33172927 DOI: 10.1136/gutjnl-2020-321753] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [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: 05/08/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Large (≥20 mm) sessile serrated lesions (L-SSL) are premalignant lesions that require endoscopic removal. Endoscopic mucosal resection (EMR) is the existing standard of care but carries some risk of adverse events including clinically significant post-EMR bleeding and deep mural injury (DMI). The respective risk-effectiveness ratio of piecemeal cold snare polypectomy (p-CSP) in L-SSL management is not fully known. DESIGN Consecutive patients referred for L-SSL management were treated by p-CSP from April 2016 to January 2020 or by conventional EMR in the preceding period between July 2008 and March 2016 at four Australian tertiary centres. Surveillance colonoscopies were conducted at 6 months (SC1) and 18 months (SC2). Outcomes on technical success, adverse events and recurrence were documented prospectively and then compared retrospectively between the subsequent time periods. RESULTS A total of 562 L-SSL in 474 patients were evaluated of which 156 L-SSL in 121 patients were treated by p-CSP and 406 L-SSL in 353 patients by EMR. Technical success was equal in both periods (100.0% (n=156) vs 99.0% (n=402)). No adverse events occurred in p-CSP, whereas delayed bleeding and DMI were encountered in 5.1% (n=18) and 3.4% (n=12) of L-SSL treated by EMR, respectively. Recurrence rates following p-CSP were similar to EMR at 4.3% (n=4) versus 4.6% (n=14) and 2.0% (n=1) versus 1.2% (n=3) for surveillance colonoscopy (SC)1 and SC2, respectively. CONCLUSIONS In a historical comparison on the endoscopic management of L-SSL, p-CSP is technically equally efficacious to EMR but virtually eliminates the risk of delayed bleeding and perforation. p-CSP should therefore be considered as the new standard of care for L-SSL treatment.
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Affiliation(s)
- W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Imogen Hartley
- Department of Gastroenterology and Hepatology, Western Health, Footscray, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kaushali Britto
- Department of gastroenterology and hepatology, Queen Elizabeth II Jubilee Hospital, Acacia Ridge, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Iddo Bar-Yishay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Scott Schoeman
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - David James Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, University Hospital Ghent, Gent, Belgium
| | - Karen Byth
- Biostatistics, Sydney University, Sydney, New South Wales, Australia
| | - David G Hewett
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Division of Gastroenterology, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia
| | - María Pellisé
- Gastroenterology, Gastroenterology Department, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Luke F Hourigan
- Department of gastroenterology and hepatology, Greenslopes Private Hospital, Brisbane, Queensland, Australia.,Department of gastroenterology and hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Alan Moss
- Department of Gastroenterology and Hepatology, Western Health, Footscray, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nicholas Tutticci
- Department of gastroenterology and hepatology, Queen Elizabeth II Jubilee Hospital, Acacia Ridge, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia .,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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26
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Shahidi N, van Hattem WA, Vosko S, Bourke MJ. Don't judge a book by its cover: except during optical evaluation. Gut 2021; 70:1252-1286. [PMID: 32220904 DOI: 10.1136/gutjnl-2020-320829] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 02/27/2020] [Accepted: 03/15/2020] [Indexed: 12/08/2022]
Affiliation(s)
- Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada .,Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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27
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Sidhu M, Shahidi N, Gupta S, Desomer L, Vosko S, Arnout van Hattem W, Hourigan LF, Lee EYT, Moss A, Raftopoulos S, Heitman SJ, Williams SJ, Zanati S, Tate DJ, Burgess N, Bourke MJ. Outcomes of Thermal Ablation of the Mucosal Defect Margin After Endoscopic Mucosal Resection: A Prospective, International, Multicenter Trial of 1000 Large Nonpedunculated Colorectal Polyps. Gastroenterology 2021; 161:163-170.e3. [PMID: 33798525 DOI: 10.1053/j.gastro.2021.03.044] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [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: 12/16/2020] [Revised: 03/16/2021] [Accepted: 03/22/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Thermal ablation of the defect margin after endoscopic mucosal resection (EMR-T) for treating large (≥20 mm) nonpedunculated colorectal polyps (LNPCPs) has shown efficacy in a randomized trial, with a 4-fold reduction, in residual or recurrent adenoma (RRA) at first surveillance colonoscopy (SC1). The clinical effectiveness of this treatment, in the real world, remains unknown. METHODS We sought to evaluate the effectiveness of EMR-T in an international multicenter prospective trial (NCT02957058). The primary endpoint was the frequency of RRA at SC1. Detailed demographic, procedural, and outcome data were recorded. Exclusion criteria were LNPCPs involving the ileo-caecal valve, the appendiceal orifice, and circumferential LNPCPs. RESULTS During 51 months (May 2016-August 2020) 1049 LNPCPs in 1049 patients (median size, 35 mm; interquartile range, 25-45 mm; right colon location, 53.5%) were enrolled. Uniform completeness of EMR-T was achieved in 989 LNPCPs (95.4%). In this study, 755/803 (94.0%) eligible LNPCPs underwent SC1 (median time to SC1, 6 months; interquartile range, 5-7 months). For LNPCPs that underwent complete EMR-T, the frequency of RRA at SC1 was 1.4% (10/707). CONCLUSIONS In clinical practice, EMR-T is a simple, inexpensive, and highly effective auxiliary technique that is likely to significantly reduce RRA at first surveillance. It should be universally used for the management of LNPCPs after EMR. https://clinicaltrials.gov; Clinical Trial Number, NCT02957058.
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Affiliation(s)
- Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Lobke Desomer
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; AZ Delta Hospital, Department of Gastroenterology and Hepatology, Roeselare, Belgium
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Greenslopes Private Hospital, Brisbane, Queensland, Australia; Gallipoli Medical Research Institute, School of Medicine, The University of Queensland, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Alan Moss
- Department of Gastroenterology and Hepatology, Footscray Hospital, Melbourne, Victoria, Australia; Department of Medicine, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Spiro Raftopoulos
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Steven J Heitman
- Departments of Medicine and Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Simon Zanati
- Department of Gastroenterology and Hepatology, Footscray Hospital, Melbourne, Victoria, Australia; Department of Gastroenterology and Hepatology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia; Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium
| | - Nicholas Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia.
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van Hattem WA, Shahidi N, Vosko S, Bar-Yishay I, Schoeman S, Sidhu M, McLeod D, Bourke MJ. Large prolapse-related lesions of the sigmoid colon. Endoscopy 2021; 53:652-657. [PMID: 32961578 DOI: 10.1055/a-1248-2175] [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: 12/10/2022]
Abstract
BACKGROUND Large prolapse-related lesions (LPRL) of the sigmoid colon have been documented histologically but may not be readily recognized endoscopically. METHODS Colonic lesions referred for endoscopic mucosal resection (EMR) were enrolled prospectively. Endoscopic features were carefully documented prior to resection. Final diagnosis was made based on established histologic criteria, including vascular congestion, hemosiderin deposition, fibromuscular hyperplasia, and crypt distortion. RESULTS Of 134 large ( ≥ 20 mm) sigmoid lesions, 12 (9.0 %) had histologic features consistent with mucosal prolapse. Distinct endoscopic features were: broad-based morphology; vascular pattern obscured by dusky hyperemia; blurred crypts of varying size and shape; and irregular spacing of sparse crypts. Focal histologic dysplasia was identified in 6 of 12 lesions (50.0 %). CONCLUSIONS LPRL of the sigmoid colon exhibit a distinct endoscopic profile. Although generally non-neoplastic, dysplasia may be present, warranting consideration of EMR.
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Affiliation(s)
- W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Iddo Bar-Yishay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Scott Schoeman
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Duncan McLeod
- Department of Pathology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Shahidi N, Vosko S, Bourke MJ. Authors' response - Delineating a rectum-specific selective resection algorithm: the time is now! Gut 2021; 70:1201-1202. [PMID: 32839199 DOI: 10.1136/gutjnl-2020-322628] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/02/2020] [Accepted: 08/03/2020] [Indexed: 12/08/2022]
Affiliation(s)
- Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada .,Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Affiliation(s)
- Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School, University of Sydney, Sydney, Australia; Division of Gastroenterology, St. Paul's Hospital, Vancouver, Canada; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School, University of Sydney, Sydney, Australia.
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31
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Vosko S, Gupta S, Shahidi N, Hourigan LF, van Hattem WA, Bar-Yishay I, Schoeman S, Sidhu M, Burgess NG, Lee EYT, Bourke MJ. Snare-tip soft coagulation is effective and efficient as a first-line modality for treating intraprocedural bleeding during Barrett's mucosectomy. Endoscopy 2021; 53:511-516. [PMID: 32659800 DOI: 10.1055/a-1218-6089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Indexed: 12/14/2022]
Abstract
UNLABELLED BACKGROUND : Intraprocedural bleeding (IPB) during multiband mucosectomy (MBM) for Barrett's neoplasia can obscure the endoscopic field. Current hemostatic devices may affect procedure continuity and technical success. Snare-tip soft coagulation (STSC) as a first-line therapy for primary hemostasis has not previously been studied in this setting. METHODS Between January 2014 and November 2019, 191 consecutive patients underwent 292 MBM procedures for Barrett's neoplasia within a prospective observational cohort in two tertiary care centers. A standard MBM technique was performed. IPB was defined as bleeding obscuring the endoscopic field that required intervention. The primary outcome was the technical success and efficacy of STSC. RESULTS IPB occurred in 63 MBM procedures (21.6 %; 95 % confidence interval 17.3 % - 26.7 %). STSC was attempted as first-line therapy in 51 IPBs, with the remainder requiring alternate therapies because of pooling of blood. STSC achieved hemostasis in 48 cases (94.1 % by per-protocol analysis; 76.2 % by intention-to-treat analysis). No apparatus disassembly was required to perform STSC. CONCLUSIONS STSC is a safe, effective, and efficient first-line hemostatic modality for IPB during MBM for Barrett's neoplasia.
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Affiliation(s)
- Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Gallipoli Medical Research Institute, School of Medicine, The University of Queensland, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Iddo Bar-Yishay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Scott Schoeman
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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McKay O, Shahidi N, Gupta S, van Hattem WA, El-Khoury T, Bourke MJ. Is it time to consider prophylactic appendectomy in patients with serrated polyposis syndrome undergoing surveillance? Gut 2021; 70:231-233. [PMID: 32694174 DOI: 10.1136/gutjnl-2020-321445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/27/2020] [Accepted: 06/29/2020] [Indexed: 12/08/2022]
Affiliation(s)
- Owen McKay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Toufic El-Khoury
- Department of Surgery, Westmead Hospital, Westmead, New South Wales, Australia.,The University of Notre Dame Australia, Darlinghurst, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead, New South Wales, Australia .,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Schoeman S, Shahidi N, Bourke MJ. Snare-based full-thickness endoscopic resection for deeply invasive colorectal neoplasia. Gastrointest Endosc 2020; 92:731-734. [PMID: 32838913 DOI: 10.1016/j.gie.2020.04.064] [Citation(s) in RCA: 2] [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] [Received: 02/22/2020] [Accepted: 04/22/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Scott Schoeman
- Westmead Hospital, Department of Gastroenterology and Hepatology, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Westmead Hospital, Department of Gastroenterology and Hepatology, Sydney, New South Wales, Australia; University of Sydney, Westmead Clinical School, Sydney, New South Wales, Australia; University of British Columbia, Department of Medicine, Vancouver, British Columbia, Canada
| | - Michael J Bourke
- Westmead Hospital, Department of Gastroenterology and Hepatology, Sydney, New South Wales, Australia; University of Sydney, Westmead Clinical School, Sydney, New South Wales, Australia
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34
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Gupta S, Shahidi N, Gilroy N, Rex DK, Burgess NG, Bourke MJ. Proposal for the return to routine endoscopy during the COVID-19 pandemic. Gastrointest Endosc 2020; 92:735-742. [PMID: 32360301 PMCID: PMC7187831 DOI: 10.1016/j.gie.2020.04.050] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 04/23/2020] [Indexed: 12/11/2022]
Abstract
In response to the coronavirus disease 2019 (COVID-19) pandemic, many jurisdictions and gastroenterological societies around the world have suspended nonurgent endoscopy. Subject to country-specific variability, it is projected that with current mitigation measures in place, the peak incidence of active COVID-19 infections may be delayed by over 6 months. Although this aims to prevent the overburdening of healthcare systems, prolonged deferral of elective endoscopy will become unsustainable. Herein, we propose that by incorporating readily available point-of-care tests and conducting accurate clinical risk assessments, a safe and timely return to elective endoscopy is feasible. Our algorithm not only focuses on the safety of patients and healthcare workers, but also assists in rationalizing the use of invaluable resources such as personal protective equipment.
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Affiliation(s)
- Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nicole Gilroy
- Department of Infectious Diseases, Westmead Hospital, Sydney, New South Wales, Australia
| | - Douglas K Rex
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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35
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Affiliation(s)
- Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia .,Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
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36
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Shahidi N, Vosko S, van Hattem WA, Sidhu M, Bourke MJ. Optical evaluation: the crux for effective management of colorectal neoplasia. Therap Adv Gastroenterol 2020; 13:1756284820922746. [PMID: 32523625 PMCID: PMC7235649 DOI: 10.1177/1756284820922746] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/06/2020] [Indexed: 02/04/2023] Open
Abstract
Advances in minimally invasive tissue resection techniques now allow for the majority of early colorectal neoplasia to be managed endoscopically. To optimize their respective risk-benefit profiles, and, therefore, appropriately select between endoscopic mucosal resection, endoscopic submucosal dissection, and surgery, the endoscopist must accurately predict the risk of submucosal invasive cancer and estimate depth of invasion. Herein, we discuss the evidence and our approach for optical evaluation of large (⩾ 20 mm) colorectal laterally spreading lesions.
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Affiliation(s)
- Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia,Westmead Clinical School, University of Sydney, Sydney, NSW, Australia,Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - W. Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia,Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
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Shahidi N, Sidhu M, Vosko S, van Hattem WA, Bar-Yishay I, Schoeman S, Tate DJ, Holt B, Hourigan LF, Lee EY, Burgess NG, Bourke MJ. Endoscopic mucosal resection is effective for laterally spreading lesions at the anorectal junction. Gut 2020; 69:673-680. [PMID: 31719129 DOI: 10.1136/gutjnl-2019-319785] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [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] [Received: 09/04/2019] [Revised: 10/17/2019] [Accepted: 10/26/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The optimal approach for removing large laterally spreading lesions at the anorectal junction (ARJ-LSLs) is unknown. Endoscopic mucosal resection (EMR) is a definitive therapy for colorectal LSLs. It is unclear whether it is an effective modality for ARJ-LSLs. DESIGN EMR outcomes for ARJ-LSLs (distal margin of ≤20 mm from the dentate line) in comparison with rectal LSLs (distal margin of >20 mm from the dentate line) were evaluated within a multicentre observational cohort of LSLs of ≥20 mm. Technical success was defined as the removal of all polypoid tissue during index EMR. Safety was evaluated by the frequencies of intraprocedural bleeding, delayed bleeding, deep mural injury (DMI) and delayed perforation. Long-term efficacy was evaluated by the absence of recurrence (either endoscopic or histologic) at surveillance colonoscopy (SC). RESULTS Between July 2008 and August 2019, 100 ARJ-LSLs and 313 rectal LSLs underwent EMR. ARJ-LSL median size was 40 mm (IQR 35-60 mm). Median follow-up at SC4 was 54 months (IQR 33-83 months). Technical success was 98%. Cancer was present in three (3%). Recurrence occurred in 15.4%, 6.8%, 3.7% and 0% at SC1-SC4, respectively. Among 30 ARJ-LSLs that received margin thermal ablation, no recurrence was identified at SC1 (0.0% vs 25.0%, p=0.002). Technical success, recurrence and adverse events were not different between groups, except for DMI (ARJ-LSLs 0% vs rectal LSLs 4.5%, p=0.027). CONCLUSION EMR is an effective technique for ARJ-LSLs and should be considered a first-line resection modality for the majority of these lesions.
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Affiliation(s)
- Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Iddo Bar-Yishay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Scott Schoeman
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - David J Tate
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,University Hospital of Gent, Gent, Belgium
| | - Bronte Holt
- Department of Gastroenterology and Hepatology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - Luke F Hourigan
- Department of Gastrenterology and Hepatology, Princess Alexandra Hospital, School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Gallipoli Medical Research Foundation, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Eric Yt Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia .,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Affiliation(s)
- Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Iddo Bar-Yishay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Bourke MJ, Shahidi N, Heitman SJ. Endoscopic Mucosal Resection Is a Dynamic Technique: Ongoing Refinement Continues to Improve Outcomes. Clin Gastroenterol Hepatol 2020; 18:754-755. [PMID: 32063266 DOI: 10.1016/j.cgh.2019.08.017] [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] [Received: 08/12/2019] [Accepted: 08/13/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School, University of Sydney, Sydney, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia; Westmead Clinical School, University of Sydney, Sydney, Australia; Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Steven J Heitman
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
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Shahidi N, Schoeman S, Bourke MJ. Acute Epigastric Pain after Gastric Endoscopic Submucosal Dissection. Gastroenterology 2020; 158:e2-e3. [PMID: 31560901 DOI: 10.1053/j.gastro.2019.09.015] [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] [Received: 08/15/2019] [Accepted: 09/03/2019] [Indexed: 12/02/2022]
Affiliation(s)
- Neal Shahidi
- Westmead Hospital, Department of Gastroenterology and Hepatology, Sydney, New South Wales, Australia; University of Sydney, Westmead Clinical School, Sydney, New South Wales, Australia; University of British Columbia, Department of Medicine, Vancouver, British Columbia, Canada
| | - Scott Schoeman
- Westmead Hospital, Department of Gastroenterology and Hepatology, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Westmead Hospital, Department of Gastroenterology and Hepatology, Sydney, New South Wales, Australia; University of Sydney, Westmead Clinical School, Sydney, New South Wales, Australia.
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41
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Shahidi N, van Hattem WA, Bourke MJ. Just relax: allowing the endoscopist and esophagus to "cool off" between radiofrequency ablation applications affects stricture formation. Gastrointest Endosc 2020; 91:455-457. [PMID: 32036952 DOI: 10.1016/j.gie.2019.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 09/12/2019] [Accepted: 09/17/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Shahidi N, Rex DK, Kaltenbach T, Rastogi A, Ghalehjegh SH, Byrne MF. Use of Endoscopic Impression, Artificial Intelligence, and Pathologist Interpretation to Resolve Discrepancies Between Endoscopy and Pathology Analyses of Diminutive Colorectal Polyps. Gastroenterology 2020; 158:783-785.e1. [PMID: 31863741 DOI: 10.1053/j.gastro.2019.10.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/17/2019] [Accepted: 10/23/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Neal Shahidi
- University of British Columbia, Department of Medicine, Vancouver, British Columbia, Canada
| | - Douglas K Rex
- Indiana University, School of Medicine, Indianapolis, Indiana
| | - Tonya Kaltenbach
- University of California-San Francisco, University San Francisco Veterans Affairs Medical Center, Division of Gastroenterology, San Francisco, California
| | - Amit Rastogi
- University of Kansas, Division of Gastroenterology, Kansas City, Kansas
| | | | - Michael F Byrne
- University of British Columbia, Department of Medicine, Vancouver, British Columbia, Canada; Satisfai Health and AI4GI joint venture, Vancouver, British Columbia, Canada.
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Shahidi N, Sidhu M, Bar-Yishay I, Bourke MJ. Mind the gap: submucosal diffusion of tattoo into the resection defect. Gastrointest Endosc 2019; 90:856-858. [PMID: 31233716 DOI: 10.1016/j.gie.2019.06.019] [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] [Received: 02/14/2019] [Accepted: 06/17/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; University of Sydney, Westmead Clinical School, Sydney, New South Wales, Australia
| | - Iddo Bar-Yishay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; University of Sydney, Westmead Clinical School, Sydney, New South Wales, Australia
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Affiliation(s)
- Michael F Byrne
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Neal Shahidi
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Douglas K Rex
- Indiana University Medical Center, Indianapolis, Indiana
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Abstract
Background/Study aim The American Society for Gastrointestinal Endoscopy (ASGE) recommends that trainees complete 150 endoscopic ultrasound (EUS) procedures before assessing competency. However, this recommendation is largely based on limited evidence and expert opinion. With new evidence suggesting that this historical threshold is underestimating training requirements, we evaluated the learning curve for achieving competency in EUS. Patients/Materials and methods Two investigators independently searched MEDLINE for full-text citations assessing the learning curve for achieving competency in EUS in the period 1946 to 25 March 2016. A learning curve was defined as either a tabulated or graphic representation of competency as a function of increasing EUS experience. Results Eight studies assessing 28 trainees and 7051 EUS procedures were included. When stratifying studies based on procedural indication: three studies assessed competency in evaluating mucosal lesions, three studies assessed competency in EUS fine-needle aspiration (EUS-FNA), and two studies assessed comprehensive competency. Among studies assessing mucosal lesion T-staging accuracy, competency was achieved by 65 to 231 procedures. Among studies assessing EUS-FNA, competency was achieved by 30 to 40 procedures. Among the two studies assessing comprehensive competency in EUS, competency was not achieved in either study across all trainees. Only four of 17 trainees reached competency by 225 to 295 EUS procedures. Conclusion As EUS competency assessment has evolved to more closely reflect independent clinical practice, the number of procedures required to achieve competency has risen well above ASGE recommendations. Advanced endoscopy training programs and specialty societies need to re-assess the structure of EUS training.
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Affiliation(s)
- Neal Shahidi
- St. Paul’s Hospital, Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - George Ou
- St. Paul’s Hospital, Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Eric Lam
- St. Paul’s Hospital, Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Robert Enns
- St. Paul’s Hospital, Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer Telford
- St. Paul’s Hospital, Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada,Corresponding author Jennifer Telford, MD Division of GastroenterologySt. Paul’s HospitalUniversity of British Columbia770-1190 Hornby StreetVancouverBCCanada+1-604-689-2004
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Shahidi N, Cheung WY. Colorectal cancer screening: Opportunities to improve uptake, outcomes, and disparities. World J Gastrointest Endosc 2016; 8:733-740. [PMID: 28042387 PMCID: PMC5159671 DOI: 10.4253/wjge.v8.i20.733] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/05/2016] [Accepted: 09/18/2016] [Indexed: 02/05/2023] Open
Abstract
Colorectal cancer screening has become a standard of care in industrialized nations for those 50 to 75 years of age, along with selected high-risk populations. While colorectal cancer screening has been shown to reduce both the incidence and mortality of colorectal cancer, it is a complex multi-disciplinary process with a number of important steps that require optimization before tangible improvements in outcomes are possible. For both opportunistic and programmatic colorectal cancer screening, poor participant uptake remains an ongoing concern. Furthermore, current screening modalities (such as the guaiac based fecal occult blood test, fecal immunochemical test and colonoscopy) may be used or performed suboptimally, which can lead to missed neoplastic lesions and unnecessary endoscopic evaluations. The latter poses the risk of adverse events, such as perforation and post-polypectomy bleeding, as well as financial impacts to the healthcare system. Moreover, ongoing disparities in colorectal cancer screening persist among marginalized populations, including specific ethnic minorities (African Americans, Hispanics, Asians, Indigenous groups), immigrants, and those who are economically disenfranchised. Given this context, we aimed to review the current literature on these important areas pertaining to colorectal cancer screening, particularly focusing on the guaiac based fecal occult blood test, the fecal immunochemical test and colonoscopy.
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Shahidi N, Marquez Azalgara V, Yoshida E. Use of Monitoring Gamma-Glutamyl Transpeptidase Levels After Liver Transplant: A Longitudinal Retrospective Analysis of a Single-Center's Experience. EXP CLIN TRANSPLANT 2016; 14:317-322. [PMID: 27221723] [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: 06/05/2023]
Abstract
OBJECTIVES Recently, gamma-glutamyl transpeptidase has garnered increased attention as a diagnostic tool in the early identification of liver disease. However, its value in liver transplant is largely unknown, as the disease processes leading to abnormal gamma-glutamyl transpeptidase levels and the expected temporal trends in gamma-glutamyl transpeptidase levels during the period after liver transplant remain unclear. MATERIALS AND METHODS Between January 2010 and August 2013, consecutive patients who underwent liver transplant at Vancouver General Hospital (Vancouver, Canada) were assessed longitudinally up to 1 year after liver transplant. A "gamma-glutamyl transpeptidase event" was defined as 2 abnormal gamma-glutamyl transpeptidase values (exceeding sex-specific limits of normal, at 55 U/L for female and 80 U/L for male patients) ≥ 1 week apart. RESULTS Our study included 147 liver transplant recipients. The median gamma-glutamyl transpeptidase level on day 1 after liver transplant was 73 U/L, which peaked to 435 U/L during the first month after liver transplant and returned to within normal parameters by 1 year. In total, there were 282 gamma-glutamyl transpeptidase events, with biliary complications (22%), acute rejection (16%), and hepatitis C virus recurrence (10%) being the most common causes. In 39% of events, no cause was identified. When attempting to identify a disease-associated event, if gamma-glutamyl transpeptidase was the initial liver biochemistry test to double in value, it had 42% sensitivity and 40% specificity. Comparatively, if gamma-glutamyl transpeptidase was the initial liver biochemistry test to become abnormal, it had 3% sensitivity and 93% specificity. CONCLUSIONS Although gamma-glutamyl transpeptidase almost universally becomes abnormal after liver transplant, a specific pathologic cause was not commonly identified. Interpreting the characteristics of gamma-glutamyl transpeptidase elevation has limited use for identifying the underlying reason for its elevation.
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Affiliation(s)
- Neal Shahidi
- From the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, British Columbia, Canada
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Abstract
Vedolizumab, an α4β7-integrin antagonist, is the first gut-selective monoclonal antibody that has been approved for the treatment of moderate-to-severe ulcerative colitis and Crohn's disease in many countries in the world. However, questions still remain regarding its appropriate use and placement in current treatment algorithms. Therefore, we sought out to evaluate the existing literature on the use of vedolizumab in inflammatory bowel disease. From inception to 21 June 2015 we searched MEDLINE for phase III randomized control trials assessing the utility of vedolizumab in inflammatory bowel disease, of which three were identified. The GEMINI trials demonstrate that vedolizumab is an effective and safe treatment for patients suffering from moderate-to-severe ulcerative colitis (GEMINI I) and Crohn's disease (GEMINI II and III). However, further studies are needed comparing its efficacy directly with anti-tumor necrosis factor therapies to allow for further delineation of current treatment algorithms as well as ensuring its long-term safety profile.
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Affiliation(s)
- Neal Shahidi
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Brian Bressler
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Shahidi N, Ou G, Telford J, Enns R. When trainees reach competency in performing ERCP: a systematic review. Gastrointest Endosc 2016; 81:1337-42. [PMID: 25841579 DOI: 10.1016/j.gie.2014.12.054] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [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] [Received: 10/31/2014] [Accepted: 12/21/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS ERCP is an advanced endoscopic procedure that is technically more challenging and carries a higher risk of adverse events compared with standard endoscopy. A discrepancy currently exists among guidelines regarding the number of ERCPs that a trainee needs to complete before procedural competency should be assessed. Our aim was to assess the learning curve for performing ERCP. METHODS Two authors independently searched MEDLINE (1946 to November 25, 2014) along with the gray literature to identify relevant citations. To warrant inclusion, citations were required to report successful trainee cannulation rate. Successful cannulation rate, set at a value of 80% or higher, was used as our baseline reference for competency. RESULTS Nine studies, assessing 137 trainees and 17,100 ERCPs, were included in our analysis. Overall, competency was achieved among the included studies between 70 to 400 ERCPs. In the 2 studies that used pancreatic duct cannulation rate, competency was achieved by 70 to 160 ERCPs. Of the 5 studies that used selective duct cannulation rate, competency was achieved by 79 to 300 ERCPs. Finally, in the 4 studies that used common bile duct cannulation rate, 2 studies reached the reference competency threshold by 160 to 400 ERCPs. On further stratification, when assessing native papilla deep common bile duct cannulation, only 1 study reached the reference competency threshold by 350 to 400 ERCPs. CONCLUSIONS Our findings suggest that as ERCP has evolved from a predominantly diagnostic to therapeutic procedure, procedural thresholds have risen well above North American training guidelines. Therefore, advanced endoscopy training programs need to reassess their current structure to ensure that procedural competency is being reached.
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Affiliation(s)
- Neal Shahidi
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - George Ou
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer Telford
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - Robert Enns
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
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Abstract
INTRODUCTION With a need for a larger armamentarium of therapeutic options for those suffering from moderate-to-severe ulcerative colitis, vedolizumab, an α4β7-integrin biologic therapy, has recently received approval in the United States, Canada and Europe. However, it is unclear where it should be positioned in relation to current therapies for moderate-to-severe ulcerative colitis. AREAS COVERED We systematically reviewed the literature for phase 1, phase 2 and phase 3 randomized controlled trials assessing the role of vedolizumab in ulcerative colitis. EXPERT OPINION Trials assessing vedolizumab highlight its arrival as an effective and safe therapy for patients suffering from ulcerative colitis.
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