Risk and Time Pattern of Recurrences After Local Endoscopic Resection of T1 Colorectal Cancer: A Meta-analysis

BACKGROUND & AIMS

Growing numbers of patients with T1 CRC are being treated with local endoscopic resection only and as a result, the need for optimization of surveillance strategies for these patients also increases. We aimed to estimate the cumulative incidence and time pattern of CRC recurrences for endoscopically treated patients with T1 CRC.

METHODS

Using a systematic literature search in PubMed, EMBASE, Web of Science and Cochrane Library (from inception till 15 May 2020), we identified and extracted data from studies describing the cumulative incidence of local or distant CRC recurrence for patients with T1 CRC treated with local endoscopic resection only. Pooled estimates were calculated using mixed-effect logistic regression models.

RESULTS

Seventy-one studies with 5167 unique, endoscopically treated patients with T1 CRC were included. The pooled cumulative incidence of any CRC recurrence was 3.3% (209 events; 95% CI, 2.6%-4.3%; I² = 54.9%), with local and distant recurrences being found at comparable rates (pooled incidences 1.9% and 1.6%, respectively). CRC-related mortality was observed in 42 out of 2519 patients (35 studies; pooled incidence 1.7%, 95% CI, 1.2%-2.2%; I² = 0%), and the CRC-related mortality rate among patients with recurrence was 40.8% (42/103 patients). The vast majority of recurrences (95.6%) occurred within 72 months of follow-up. Pooled incidences of any CRC recurrence were 7.0% for high-risk T1 CRCs (28 studies; 95% CI, 4.9%-9.9%; I² = 48.1%) and 0.7% (36 studies; 95% CI, 0.4%-1.2%; I² = 0%) for low-risk T1 CRCs.

CONCLUSIONS

Our meta-analysis provides quantitative outcome measures which are relevant to guidelines on surveillance after local endoscopic resection of T1 CRC.

Endoscopy management algorithms: role of cyanoacrylate glue injection and self-expanding metal stents in acute variceal haemorrhage

Mortality from acute variceal bleeding (AVB) has improved markedly over the last 2-3 decades due to increased specialisation and standardisation of medical and endoscopic practice culminating in the production of consensus guidance based on expert opinion. Nonetheless, despite greater exposure, training and endoscopic practices, 30-day mortality still remains high at around 30%. This is a reflection of the high morbidity with liver disease, and limited endoscopic experience and/or endoscopic techniques used by the majority of general endoscopists. Clinical necessity defines our drive for further endoscopic innovation to improve 'best practice' and, therefore, clinical outcomes accordingly. Sclerotherpy, variceal band ligation and/or rescue balloon tamponade have been entrenched in most treatment algorithms over the decades. However, in recent years and albeit limited to specialised liver centres, cyanoacrylate glue injection therapy (for oesophageal and gastric varices), and the placement of a self-expanding metallic stent for oesophageal varices have begun to offer improved endoscopic care in experienced hands. Yet even in specialised centres, their application is sporadic and operator dependent. Here, we discuss the evidence of these newer endoscopic approaches, and hope to propose their inclusion in endoscopic therapy algorithms for 'best practice' management of AVB in all appropriately supported endoscopy units.

Factors at presentation predictive of a requirement for endoscopic therapy in patients presenting with overt upper gastrointestinal haemorrhage: a retrospective observational study

INTRODUCTION

In patients with upper gastrointestinal haemorrhage (UGIH), endoscopic treatment of high-risk lesions reduces mortality. Performing out of office hours endoscopy places a strain on endoscopy services. This analysis aims to identify factors at presentation associated with lesions requiring endoscopic therapy, allowing triage of those likely to receive benefit from acute out of hours endoscopy.

METHODS

Patients presenting between 17 March 2001 and 12 October 2010 with UGIH had clinical and laboratory features on presentation, endoscopic findings and administered treatment recorded. Patients with known cirrhotic liver disease were excluded. Logistic regression was performed, identifying factors at presentation associated with a requirement of endoscopic therapy (RET), which were then used to create a scoring system predictive of RET.

RESULTS

In all, 1492 patients were analysed. The presence on presentation of fresh melaena (OR = 3.18, p<0.001), fresh haematemesis (OR=2.13, p<0.001), haemoglobin<130 g/L (OR=2.65, p<0.001), urea >10 mmol/L (OR=2.10, p<0.001), systolic blood pressure <100 mm  Hg (OR=1.85, p<0.001), inpatient status (OR=1.43, p=0.04), a history of peptic ulcer disease (OR=1.96, p=0.02), male sex (OR=1.45, p=0.01), presentation within 8 h of symptom onset (OR=1.48, p=0.02), coffee ground vomitus (OR=0.47, p=0.004) and warfarin use (OR=0.57, p=0.005) were associated with RET. Using a simple scoring system (fresh haematemesis=2, fresh melaena=2, haemoglobin <130=2, urea >10=1, BP <100=1, male sex=1, history of peptic ulcer disease=1), a score ≥7 was associated with RET in 45% of cases and a score ≤4 in 7%.

CONCLUSIONS

Application of this scoring system when assessing patients presenting with UGIH out of office hours may help predict the likelihood of RET, and aid in the triage of endoscopy. Prospective validation of this score in an external cohort is required.

Colonic stenting: a practical update

Colonic stenting is part of the UK service provision guidelines for colorectal cancer. However, there are issues about availability and expertise within the UK, and controversies remain regarding various clinical and technical aspects of the technique. Based on the current evidence, this article will provide a practical update on the indications, the clinical and technical considerations and the remaining unanswered questions regarding colonic stenting.