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O’Sullivan T, Bourke MJ. Endoscopic Resection of Neoplasia in the Lower GI Tract: A Clinical Algorithm. Visc Med 2024; 40:217-227. [PMID: 39157731 PMCID: PMC11326768 DOI: 10.1159/000539219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/03/2024] [Indexed: 08/20/2024] Open
Abstract
Background Colorectal cancer is a highly prevalent malignancy and a significant driver of cancer mortality and health-related expenditure worldwide. Polyp removal reduces the incidence and mortality of colorectal cancer. In 2024, endoscopists have an array of resection modalities at their disposal. Each technique requires a unique skillset and has individual advantages and limitations. Consequently, resection in the colorectum requires an evidence-based algorithm approach that considers these factors. Summary A literature review of endoscopic resection for colonic neoplasia was conducted. Best supporting scientific evidence was summarized for the endoscopic resection of diminutive polyps, large ≥20 mm lesions and polyps containing invasive cancer. Factors including resection modality, complications and lesion selection were explored to inform an algorithm approach to colorectal resection. Key Messages Endoscopic resection in the colorectum is not a one-size-fits-all approach. Detailed understanding of polyp size, location, morphology and predicted histology are critical factors that inform appropriate endoscopic resection practice.
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Affiliation(s)
- Timothy O’Sullivan
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
- University of Sydney, Westmead Clinical School, Westmead, NSW, Australia
| | - Michael J. Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia
- University of Sydney, Westmead Clinical School, Westmead, NSW, Australia
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2
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Gomez Cifuentes JD, Berger S, Caskey K, Jove A, Sealock R, Hair C, Velez M, Jarbrink-Sehgal M, Thrift AP, da Costa WL, Gyanprakash K. New Model to Predict Recurrence After Endoscopic Mucosal Resection of Non-pedunculated Colonic Polyps ≥ 20 mm. Dig Dis Sci 2023; 68:3935-3942. [PMID: 37548897 DOI: 10.1007/s10620-023-08054-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/21/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Polyp recurrence is common after endoscopic mucosal resection (EMR) of non-pedunculated colonic polyps ≥ 20 mm. Two models haven been published for polyp recurrence prediction: Sydney EMR recurrence tool (SERT) and the size, morphology, colonic site, and access to target (SMSA) score. None of these models have been evaluated in a real-world United States (U.S.) cohort. We aimed to evaluate the external validity of these two models and develop a new model. METHODS Retrospective cohort study of patients with non-pedunculated polyps ≥ 20 mm that underwent EMR between 1/1/2012 and 6/30/2020. Univariate and multivariate analysis were performed to identify predictors of polyp recurrence to build a new model. Receiver Operating Characteristic (ROC) curves for the new model, SERT and a modified version of SMSA were derived and compared. RESULTS A total of 461 polyps from 461 unique patients were included for analysis. The average polyp size was 29.1 ± 12.4 mm. Recurrence rate at first or second surveillance colonoscopy was 29.0% at a 15.6 months median follow up (IQR 12.3-17.4). A model was created with 4 variables from index colonoscopy: size > 40 mm, tubulovillous adenoma histology, right colon location and piecemeal resection. ROC curves showed that the Area Under the ROC (AUC) for the new model was 0.618, for SERT 0.538 and for mSMSA 0.550. CONCLUSION SERT score and mSMSA have poor external validity to predict polyp recurrence after EMR of non-pedunculated polyps > 20 mm. Our new model is simpler and performs better in this multiethnic, non-referral cohort from the U.S.
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Affiliation(s)
| | - Scott Berger
- Internal Medicine Department, Baylor College of Medicine, Houston, TX, USA.
| | | | - Andre Jove
- Baylor College of Medicine, Houston, TX, USA
| | - Robert Sealock
- Division of Gastroenterology, Baylor College of Medicine, Houston, TX, USA
| | - Clark Hair
- Division of Gastroenterology, Baylor College of Medicine, Houston, TX, USA
| | - Maria Velez
- Division of Gastroenterology, Baylor College of Medicine, Houston, TX, USA
| | | | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Wilson L da Costa
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Kaltenbach T, Anderson JC, Burke CA, Dominitz JA, Gupta S, Lieberman D, Robertson DJ, Shaukat A, Syngal S, Rex DK. Endoscopic Removal of Colorectal Lesions-Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2020; 91:486-519. [PMID: 32067745 DOI: 10.1016/j.gie.2020.01.029] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Tonya Kaltenbach
- Veterans Affairs San Francisco, University California-San Francisco, San Francisco, California.
| | - Joseph C Anderson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; University of Connecticut Health Center, Farmington, Connecticut
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Jason A Dominitz
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - Samir Gupta
- Veterans Affairs San Diego Healthcare System, San Diego, California; University of California-San Diego, San Diego, California
| | | | - Douglas J Robertson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Aasma Shaukat
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota
| | - Sapna Syngal
- Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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4
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Endoscopic Removal of Colorectal Lesions: Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2020; 115:435-464. [PMID: 32058340 DOI: 10.14309/ajg.0000000000000555] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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5
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Kaltenbach T, Anderson JC, Burke CA, Dominitz JA, Gupta S, Lieberman D, Robertson DJ, Shaukat A, Syngal S, Rex DK. Endoscopic Removal of Colorectal Lesions-Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2020; 158:1095-1129. [PMID: 32122632 DOI: 10.1053/j.gastro.2019.12.018] [Citation(s) in RCA: 186] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Tonya Kaltenbach
- Veterans Affairs San Francisco, University California-San Francisco, San Francisco, California.
| | - Joseph C Anderson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; University of Connecticut Health Center, Farmington, Connecticut
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Jason A Dominitz
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - Samir Gupta
- Veterans Affairs San Diego Healthcare System, San Diego, California; University of California-San Diego, San Diego, California
| | | | - Douglas J Robertson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Aasma Shaukat
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota
| | - Sapna Syngal
- Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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6
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Kim JY, Han SJ, Jung Y, Cho YS, Chung IK, Lee TH, Park SH, Cho HD, Kim SJ, Hwangbo Y. The relationship between local recurrence and positive lateral margin after en bloc resection of colorectal neoplasm. Scand J Gastroenterol 2018; 53:1541-1546. [PMID: 30600737 DOI: 10.1080/00365521.2018.1547419] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The factors associated with recurrence of colonic neoplasm after endoscopic resection with a positive lateral margin are not well known. Thus, we evaluate the relationship between recurrence and positive lateral margin after endoscopic en bloc resection of colorectal neoplasm. METHODS A retrospective review of 9302 patients who underwent colonic endoscopic resection from January 2008 to January 2015. Of these, a total of 76 patients with positive lateral margins with clear evidence of the its location on endoscopic picture after endoscopic en bloc resection of colorectal neoplasm (>10 mm) were included. RESULTS Ten of 76 (13.2%) patients experienced recurrence during the follow-up period (mean f/u month, 21.7 ± 15.6). In cases with positive lateral margins, the 3- and 5-year local recurrence rate of colorectal neoplasm was 28.1% and 40.1%, respectively. The histological features of the recurrence group were as follows: one case of adenocarcinoma [from low-grade adenoma (LGA)]; two cases of high-grade adenoma (HGA) (one from HGA and one from LGA); and seven cases of LGA (four from adenocarcinoma, two from LGA, and one from HGA). The mean age of patients, locations of the lesions, and histologic type were not significantly associated with local recurrence. In multivariate Poisson regression analyses, total length of lateral margin involvement ≥8 mm (relative risk 12.51; 95% CI 1.11-140.34, p = .040) was a significant predictor of local recurrence. CONCLUSIONS Positive lateral margins ≥8 mm may be a reliable predictor of local recurrence after endoscopic en bloc resection of colorectal neoplasm.
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Affiliation(s)
- Jae Yun Kim
- a Division of Gastroenterology, Department of Internal Medicine , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
| | - Su Jung Han
- a Division of Gastroenterology, Department of Internal Medicine , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
| | - Yunho Jung
- a Division of Gastroenterology, Department of Internal Medicine , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
| | - Young Sin Cho
- a Division of Gastroenterology, Department of Internal Medicine , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
| | - Il-Kwun Chung
- a Division of Gastroenterology, Department of Internal Medicine , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
| | - Tae Hoon Lee
- a Division of Gastroenterology, Department of Internal Medicine , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
| | - Sang-Heum Park
- a Division of Gastroenterology, Department of Internal Medicine , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
| | - Hyun Deuk Cho
- b Department of Pathology , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
| | - Sun-Joo Kim
- a Division of Gastroenterology, Department of Internal Medicine , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
| | - Young Hwangbo
- c Department of Preventive Medicine , Soonchunhyang University College of Medicine, Cheonan Hospital , Cheonan , Republic of Korea
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Kumar AS, Lee JK. Colonoscopy: Advanced and Emerging Techniques-A Review of Colonoscopic Approaches to Colorectal Conditions. Clin Colon Rectal Surg 2017; 30:136-144. [PMID: 28381945 DOI: 10.1055/s-0036-1597312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A complete colonoscopy is key in the diagnostic and therapeutic approaches to a variety of colorectal diseases. Major challenges are incomplete polyp removal and missed polyps, particularly in the setting of a difficult colonoscopy. There are a variety of both well-established and newer techniques that have been developed to optimize polyp detection, perform complete polypectomy, and endoscopically treat various complications and conditions such as strictures and perforations. The objective of this article is to familiarize the colorectal surgeon with techniques utilized by advanced endoscopists.
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Affiliation(s)
- Anjali S Kumar
- Colorectal Surgery Program, Virginia Mason Medical Center, Seattle, Washington
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8
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Gómez EJ, Izcovich A. Should prophylactic measures to prevent postpolypectomy bleeding after resection of large colorectal polyps be used? Medwave 2016; 16 Suppl 3:e6496. [PMID: 27513877 DOI: 10.5867/medwave.2016.6496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Post-polypectomy bleeding after colonoscopy with resection of large colorectal polyps can cause significant morbidity (readmission for monitoring, transfusion, repeat endoscopy and therapy) and a significant cost to hospitals and insurers. Nevertheless prophylactic endoscopic measures could reduce risk of post-polypectomy bleeding. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified two systematic reviews including 10 randomized trials. We combined the evidence using meta-analysis and generated a summary of findings table following the GRADE approach. We concluded prophylactic endoscopic measures could be effective in reducing post-polypectomy bleeding after resection of large colorectal polyps.
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Affiliation(s)
- Estanislao J Gómez
- Servicios de Gastroenterología y Endoscopía Digestiva, Hospital Alemán, Buenos Aires, Argentina; Programa de Medicina Basada en Pruebas, Hospital Alemán, Buenos Aires, Argentina Address: Hospital Alemán de Buenos Aires, Av. Pueyrredon 1640, CP C118AAT, +54114827700.
| | - Ariel Izcovich
- Servicios de Gastroenterología y Endoscopía Digestiva, Hospital Alemán, Buenos Aires, Argentina; Programa de Medicina basada en pruebas, Hospital Alemán, Buenos Aires, Argentina
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9
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Kim TO. Optimal Colonoscopy Surveillance Interval after Polypectomy. Clin Endosc 2016; 49:359-63. [PMID: 27484812 PMCID: PMC4977746 DOI: 10.5946/ce.2016.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 07/12/2016] [Indexed: 12/27/2022] Open
Abstract
The detection and removal of adenomatous polyps and postpolypectomy surveillance are considered important for the control of colorectal cancer (CRC). Surveillance using colonoscopy is an effective tool for preventing CRC after colorectal polypectomy, especially if compliance is good. In current practice, the intervals between colonoscopies after polypectomy are variable. Different recommendations for recognizing at risk groups and defining surveillance intervals after an initial finding of colorectal adenomas have been published. However, high-grade dysplasia and the number and size of adenomas are known major cancer predictors. Based on this, a subgroup of patients that may benefit from intensive surveillance colonoscopy can be identified.
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Affiliation(s)
- Tae Oh Kim
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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10
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Isaacson G. Inside-Out Complete Tonsillectomy: Extended Intracapsular Tonsillectomy for Severe Sore Throat. Ann Otol Rhinol Laryngol 2016; 114:757-61. [PMID: 16285265 DOI: 10.1177/000348940511401004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: This consecutive case series is presented to describe inside-out complete tonsillectomy and to assess its effects on postoperative pain and bleeding and its initial effectiveness in controlling recurrent sore throat and peritonsillar abscess formation. Methods: Bipolar electrosurgical scissors are used for bloodless resection of 90% of the tonsillar mass. During controlled resection, tonsil tissue is intentionally left at the superior and inferior poles and at the deepest part of the tonsillar fossa to provide coverage for nutrient arteries and the tonsillar plexus of veins. This tissue is then electrodesiccated and removed under direct vision and indirect mirror guidance to achieve complete tonsillectomy. Results: One hundred eighty-three consecutive tonsillectomies were performed by a single surgeon in a 16-month period, 47 of which were for the indication of recurrent sore throat (44) or recurrent peritonsillar abscess (3). Among these 47 children, there were 2 readmissions for dehydration. There were no immediate or delayed bleeding episodes. The average child required 4 days of narcotic pain medication. The mean annualized number of severe sore throats decreased from 5.24 before operation to 0.36 after operation (p <.0001, Student's paired t-test). There were no recurrent peritonsillar abscesses. Conclusions: Inside-out complete tonsillectomy achieves the surgical goal of complete tonsillectomy with the smallest possible wound and minimal injury to the surrounding tissue. The perioperative morbidity is markedly decreased compared to that of historical controls. The initial results suggest effectiveness similar to that of extracapsular tonsillectomy.
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Affiliation(s)
- Glenn Isaacson
- Department of Otolaryngology-Head and Neck Surgery, Temple University School of Medicine, Temple University Children's Medical Center, Philadelphia, Pennsylvania, USA
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11
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Law R, Das A, Gregory D, Komanduri S, Muthusamy R, Rastogi A, Vargo J, Wallace MB, Raju GS, Mounzer R, Klapman J, Shah J, Watson R, Wilson R, Edmundowicz SA, Wani S. Endoscopic resection is cost-effective compared with laparoscopic resection in the management of complex colon polyps: an economic analysis. Gastrointest Endosc 2016; 83:1248-57. [PMID: 26608129 DOI: 10.1016/j.gie.2015.11.014] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 11/07/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic resection (ER) is an efficacious treatment for complex colon polyps (CCPs). Many patients are referred for surgical resection because of concerns over procedural safety, incomplete polyp resection, and adenoma recurrence after ER. Efficacy data for both resection strategies are widely available, but a paucity of data exist on the cost-effectiveness of each modality. The aim of this study was to perform an economic analysis comparing ER and laparoscopic resection (LR) strategies in patients with CCP. METHODS A decision analysis tree was constructed using decision analysis software. The 2 strategies (ER vs LR) were evaluated in a hypothetical cohort of patients with CCPs. A hybrid Markov model with a 10-year time horizon was used. Patients entered the model after colonoscopic diagnosis at age 50. Under Strategy I, patients underwent ER followed by surveillance colonoscopy at 3 to 6 months and 12 months. Patients with failed ER and residual adenoma at 12 months were referred for LR. Under Strategy II, patients underwent LR as primary treatment. Patients with invasive cancer were excluded. Estimates regarding ER performance characteristics were obtained from a systematic review of published literature. The Centers for Medicare & Medicaid Services (2012-2013) and the 2012 Healthcare Cost and Utilization Project databases were used to determine the costs and loss of utility. We assumed that all procedures were performed with anesthesia support, and patients with adverse events in both strategies required inpatient hospitalization. Baseline estimates and costs were varied by using a sensitivity analysis through the ranges. RESULTS LR was found to be more costly and yielded fewer quality-adjusted life-years (QALYs) compared with ER. The cost of ER of a CCP was $5570 per patient and yielded 9.640 QALYs. LR of a CCP cost $18,717 per patient and yielded fewer QALYs (9.577). For LR to be more cost-effective, the thresholds of 1-way sensitivity analyses were (1) technical success of ER for complete resection in <75.8% of cases, (2) adverse event rates for ER > 12%, and (3) LR cost of <$14,000. CONCLUSIONS Our data suggest that ER is a cost-effective strategy for removal of CCPs. The effectiveness is driven by high technical success and low adverse event rates associated with ER, in addition to the increased cost of LR.
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Affiliation(s)
- Ryan Law
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ananya Das
- Arizona Digestive Health, Gilbert, Arizona, USA
| | - Dyanna Gregory
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Raman Muthusamy
- Division of Digestive Diseases, University of California-Los Angeles, Los Angeles, California, USA
| | - Amit Rastogi
- Division of Gastroenterology, The University of Kansas Hospital, Kansas City, Kansas, USA
| | - John Vargo
- Digestive Diseases Institute, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic-Jacksonville, Jacksonville, Florida, USA
| | - G S Raju
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rawad Mounzer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jason Klapman
- Gastrointestinal Oncology Department, Moffitt Cancer Center, Tampa, Florida, USA
| | - Janak Shah
- Department of Gastroenterology, California Pacific Medical Center, San Francisco, California, USA
| | - Rabindra Watson
- Division of Digestive Diseases, University of California-Los Angeles, Los Angeles, California, USA
| | - Robert Wilson
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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12
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Hassan C, Repici A, Sharma P, Correale L, Zullo A, Bretthauer M, Senore C, Spada C, Bellisario C, Bhandari P, Rex DK. Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis. Gut 2016; 65:806-20. [PMID: 25681402 DOI: 10.1136/gutjnl-2014-308481] [Citation(s) in RCA: 266] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 01/20/2015] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of endoscopic resection of large colorectal polyps. DESIGN Relevant publications were identified in MEDLINE/EMBASE/Cochrane Central Register for the period 1966-2014. Studies in which ≥20 mm colorectal neoplastic lesions were treated with endoscopic resection were included. Rates of postendoscopic resection surgery due to non-curative resection or adverse events, as well as the rates of complete endoscopic removal, invasive cancer, adverse events, recurrence and mortality, were extracted. Study quality was ascertained according to Newcastle-Ottawa Scale. Forest plot was produced based on random effect models. I2 statistic was used to describe the variation across studies due to heterogeneity. Meta-regression analysis was also performed. RESULTS 50 studies including 6442 patients and 6779 large polyps were included in the analyses. Overall, 503 out of 6442 patients (pooled rate: 8%, 95% CI 7% to 10%, I2=78.6%) underwent surgery due to non-curative endoscopic resection, and 31/6442 (pooled rate: 1%, 95% CI 0.7% to 1.4%, I2=0%) to adverse events. Invasive cancer at histology, non-curative endoscopic resection, synchronous lesions and recurrence accounted for 58%, 28%, 2.2% and 5.9% of all the surgeries, respectively. Endoscopic perforation occurred in 96/6595 (1.5%, 95% CI 1.2% to 1.7%) polyps, while bleeding in 423/6474 (6.5%, 95% CI 5.9% to 7.1%). Overall, 5334 patients entered in surveillance, 502/5836 (8.6%, 95% CI 7.9% to 9.3%) being lost at follow-up. Endoscopic recurrence was detected in 735/5334 patients (13.8%, 95% CI 12.9% to 14.7%), being an invasive cancer in 14/5334 (0.3%, 95% CI 0.1% to 0.4%). Endoscopic treatment was successful in 664/735 cases (90.3%, 95% CI 88.2% to 92.5%). Mortality related with management of large polyps was reported in 5/6278 cases (0.08%, 95% CI 0.01% to 0.15%). CONCLUSIONS Endoscopic resection of large polyps appeared to be an extremely effective and safe intervention. However, an adequate endoscopic surveillance is necessary for its long-term efficacy.
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Affiliation(s)
- C Hassan
- Endoscopy Unit, 'Nuovo Regina Margherita Hospital', Rome, Italy
| | - A Repici
- Digestive Endoscopy Unit, Istituto Clinico Humanitas, Milan, Italy
| | - P Sharma
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Kansas, USA
| | | | - A Zullo
- Endoscopy Unit, 'Nuovo Regina Margherita Hospital', Rome, Italy
| | - M Bretthauer
- Department of Health Economy and Health Management, University of Oslo, Oslo, Norway Gastroenterology Unit, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - C Senore
- AOU S Giovanni Battista-CPO Piemonte, SCDO Epidemiologia dei Tumori 2, Turin, Italy
| | - C Spada
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
| | | | - P Bhandari
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
| | - D K Rex
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, Indiana, USA
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13
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Fujiya M, Tanaka K, Dokoshi T, Tominaga M, Ueno N, Inaba Y, Ito T, Moriichi K, Kohgo Y. Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection. Gastrointest Endosc 2015; 81:583-95. [PMID: 25592748 DOI: 10.1016/j.gie.2014.07.034] [Citation(s) in RCA: 263] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 07/11/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND EMR and endoscopic submucosal dissection (ESD) are used frequently to remove colon neoplasms. However, the predominance of these procedures has not yet been thoroughly explored. OBJECTIVE To compare the efficacy and adverse events related to EMR with those related to ESD for colon neoplasms. DESIGN A meta-analysis of 8 studies published between 2005 and 2013. SETTING Multicenter review. PATIENTS Patients from 8 studies yielding 2299 lesions. INTERVENTIONS EMR or ESD. MAIN OUTCOME MEASUREMENTS En bloc resection, curative resection, recurrence, and adverse events. RESULTS The pooled odds ratios (OR) (OR [95% confidence interval]) for the tumor size, length of the procedure, en bloc resection, curative resection, recurrence, additional surgery, delayed bleeding, and perforation by ESD versus EMR were 7.38 (6.42-8.34), 58.07 (36.27-79.88), 6.84 (3.30-14.18), 4.26 (3.77-6.57), 0.08 (0.04-0.17), 2.16 (1.16-4.03), 0.85 (0.45-1.60), and 4.96 (2.79-8.85), respectively. LIMITATIONS This analysis included only nonrandomized studies. CONCLUSION The size of the tumor and rate of en bloc resection and curative resection were higher, and the rate of recurrence was lower in the ESD group versus the EMR group. However, in the ESD group, the procedure was longer, and the rate of additional surgery and perforation was higher, suggesting that the indications for ESD should therefore be rigorously determined in order to avoid such problems.
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Affiliation(s)
- Mikihiro Fujiya
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Kazuyuki Tanaka
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Tatsuya Dokoshi
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Motoya Tominaga
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Nobuhiro Ueno
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yuhei Inaba
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Takahiro Ito
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Kentaro Moriichi
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yutaka Kohgo
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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Seo JY, Chun J, Lee C, Hong KS, Im JP, Kim SG, Jung HC, Kim JS. Novel risk stratification for recurrence after endoscopic resection of advanced colorectal adenoma. Gastrointest Endosc 2015; 81:655-64. [PMID: 25500328 DOI: 10.1016/j.gie.2014.09.064] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 09/29/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Advanced colorectal adenoma (ACA) refers to adenomas with the following predictive characteristics: ≥1 cm in diameter, and/or villous component, and/or high-grade dysplasia. ACA has high risk of transforming to colorectal cancer, and the recurrence rate is relatively high. OBJECTIVE To assess the outcomes of patients with ACA undergoing endoscopic resection and to identify risk factors for local recurrence and development of metachronous advanced neoplasm. DESIGN Retrospective cohort study. SETTING Tertiary care medical center. PATIENTS From 2005 to 2011, the records of 3625 patients who underwent colonoscopic polypectomy at Seoul National University Hospital were retrospectively reviewed. Patients with synchronous colorectal cancers, inflammatory bowel disease, previous colorectal resection, loss to follow-up, and incomplete resection were excluded. INTERVENTION Endoscopic resection for ACA. MAIN OUTCOME MEASUREMENTS Local recurrence and metachronous advanced neoplasm. RESULTS The study included 917 patients with 1206 ACAs. The median duration of follow-up was 28.5 months (interquartile range, 12.8-51.7). Independent risk factors for local recurrence included ACA with 2 or more predictive characteristics (adjusted hazard ratio [HR], 2.46; 95% confidence interval [CI], 1.11-5.48; P = .027) and piecemeal resection (adjusted HR, 6.96; 95% CI, 1.58-30.71; P = .010). Independent risk factors for metachronous advanced neoplasm were male gender (adjusted HR, 1.65; 95% CI, 1.02-2.65; P = .041), ≥3 adenomas (adjusted HR, 2.56; 95% CI, 1.72-3.82; P < .001), and ≥3 ACAs (adjusted HR, 1.44; 95% CI, 1.01-2.06; P = .045). LIMITATIONS Retrospective design. CONCLUSION ACAs with 2 or more predictive characteristics recurred locally at a higher rate than ACAs with 1 predictive characteristic. These results suggest that patients who are found to have ACAs with 2 or more predictive factors at index colonoscopy are at higher risk for local recurrence, and follow-up colonoscopy should be performed sooner.
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Affiliation(s)
- Ji Yeon Seo
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jaeyoung Chun
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Changhyun Lee
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Kyoung Sup Hong
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Pil Im
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Chae Jung
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Joo Sung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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15
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Abstract
The major role of colonoscopy with polypectomy in reducing the incidence of and mortality from colorectal cancer has been firmly established. Yet there is cause to be uneasy. One of the most striking recent findings is that there is an alarmingly high incomplete polyp removal rate. This phenomenon, together with missed polyps during screening colonoscopy, is thought to be responsible for the majority of interval cancers. Knowledge of serrated polyps needs to broaden as well, since they are quite often missed or incompletely removed. Removal of small and diminutive polyps is almost devoid of complications. Cold snare polypectomy seems to be the best approach for these lesions, with biopsy forcep removal reserved only for the tiniest of polyps. Hot snare or hot biopsy forcep removal of these lesions is no longer recommended. Endoscopic mucosal resection and endoscopic submucosal dissection have proven to be effective in the removal of large colorectal lesions, avoiding surgery in the majority of patients, with acceptably low complication rates. Variants of these approaches, as well as new hybrid techniques, are being currently tested. In this paper, we review the current status of the different approaches in removing polypoid and nonpolypoid lesions of the colon, their complications, and future directions in the prevention of colorectal cancer.
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Affiliation(s)
- Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Manol Jovani
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Cesare Hassan
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
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16
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Endoscopic piecemeal resection of large colorectal polyps with long-term followup. Surg Endosc 2014; 28:2641-8. [PMID: 24695984 DOI: 10.1007/s00464-014-3516-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 03/17/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Colonoscopic removal of large colorectal polyps is challenging and requires advanced endoscopic technique. Successful endoscopic management not only avoids the morbidity of surgery but also risks perforation, hemorrhage, and recurrence. METHODS This study is a retrospective review of a prospectively maintained database of all patients undergoing cautery snare piecemeal polypectomy for large colorectal polyps by a single operator over 20 years with long-term followup. RESULTS 231 patients underwent 269 piecemeal polypectomies over a 20 year period. The complication rate was 4.3 %. Malignancy was identified in 25 (10.8 %) of patients. Local recurrences occurred in 24 % of patients with benign adenomas. The vast majority of these were managed with repeat endoscopy. Overall, benign large polyps were managed successfully endoscopically in 94.4 % of patients. CONCLUSIONS Piecemeal polypectomy is effective and safe for the management of large colorectal polyps. With long-term followup, the recurrence rate is appreciable, but most recurrences can be successfully managed with further endoscopic intervention. More complex techniques such as endoscopic submucosal dissection are usually unnecessary.
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17
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Rüth S, Spatz J, Anthuber M. Is There an Indication for Surgical Resection in Colorectal Adenoma? VISZERALMEDIZIN 2014; 30:46-51. [PMID: 26288581 PMCID: PMC4513810 DOI: 10.1159/000358540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Due to the adenoma-carcinoma sequence, complete removal of colorectal polyps is essential. METHOD This article analyzes the role of surgery in the removal of colorectal adenoma. RESULTS Nowadays, most adenomas are removed properly by endoscopic methods. Also in the resection of giant polyps and recurrent adenoma endoscopic data is convincing. Therefore, surgical resection of colorectal adenomas is required in the case of endoscopic inaccessibility. Reasons for this may be the location of the polyp, incomplete endoscopic resection, or suspected malignancy. Endoscopic or limited surgical resection of malignant adenomas is acceptable only if 'low-risk' criteria are fulfilled. Otherwise oncologic radical resection is recommended. In general, radical resection is also necessary in the case of polyps that are not suitable for endoscopic removal, because here the rate of colorectal carcinoma is high. CONCLUSION If a surgical approach is necessary, minimally invasive surgery in the hands of an experienced laparoscopic surgeon is a suitable option. Adenomas in the lower two thirds of the rectum are suitable for transanal full-thickness resection. This is done by conventional resection or transanal endoscopic microsurgery. The histopathological preparation of these specimens provides diagnostic and therapeutic benefits, particularly compared to piecemeal resection of early carcinoma.
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Affiliation(s)
- Stefan Rüth
- Allgemein-, Viszeral- und Transplantationschirurgie, Klinikum Augsburg, Germany
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18
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Steele SR, Johnson EK, Champagne B, Davis B, Lee S, Rivadeneira D, Ross H, Hayden DA, Maykel JA. Endoscopy and polyps-diagnostic and therapeutic advances in management. World J Gastroenterol 2013; 19:4277-4288. [PMID: 23885138 PMCID: PMC3718895 DOI: 10.3748/wjg.v19.i27.4277] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Revised: 05/30/2013] [Accepted: 06/10/2013] [Indexed: 02/06/2023] Open
Abstract
Despite multiple efforts aimed at early detection through screening, colon cancer remains the third leading cause of cancer-related deaths in the United States, with an estimated 51000 deaths during 2013 alone. The goal remains to identify and remove benign neoplastic polyps prior to becoming invasive cancers. Polypoid lesions of the colon vary widely from hyperplastic, hamartomatous and inflammatory to neoplastic adenomatous growths. Although these lesions are all benign, they are common, with up to one-quarter of patients over 60 years old will develop pre-malignant adenomatous polyps. Colonoscopy is the most effective screening tool to detect polyps and colon cancer, although several studies have demonstrated missed polyp rates from 6%-29%, largely due to variations in polyp size. This number can be as high as 40%, even with advanced (> 1 cm) adenomas. Other factors including sub-optimal bowel preparation, experience of the endoscopist, and patient anatomical variations all affect the detection rate. Additional challenges in decision-making exist when dealing with more advanced, and typically larger, polyps that have traditionally required formal resection. In this brief review, we will explore the recent advances in polyp detection and therapeutic options.
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19
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Abstract
Endoscopic resection, including polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection, is the preferred treatment method of large colorectal polyps. Its safety and efficacy have been shown. Endoscopic removal techniques are important because they provide a resection specimen for precise histopathologic staging to further direct diagnosis, prognosis, and management decisions. Used according to its indications, it provides curative resection and obviates the higher morbidity, mortality, and cost associated with alternative surgical treatment.
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20
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Yang DH, Hong SN, Kim YH, Hong SP, Shin SJ, Kim SE, Lee BI, Lee SH, Park DI, Kim HS, Yang SK, Kim HJ, Kim SH, Kim HJ. Korean guidelines for postpolypectomy colonoscopy surveillance. Clin Endosc 2012; 45:44-61. [PMID: 22741132 PMCID: PMC3363120 DOI: 10.5946/ce.2012.45.1.44] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Revised: 01/17/2012] [Accepted: 01/17/2012] [Indexed: 12/16/2022] Open
Abstract
Postpolypectomy surveillance has become a major indication for colonoscopy as a result of increased use of screening colonoscopy in Korea. In this report, a careful analytic approach was used to address all available evidences to delineate the predictors for advanced neoplasia at surveillance colonoscopy and we elucidated the high risk findings of the index colonoscopy as follows: 3 or more adenomas, any adenoma larger than 10 mm, any tubulovillous or villous adenoma, any adenoma with high-grade dysplasia, and any serrated polyps larger than 10 mm. Surveillance colonoscopy should be performed five years after the index colonoscopy for those without any high-risk findings and three years after the index colonoscopy for those with one or more high risk findings. However, the surveillance interval can be shortened considering the quality of the index colonoscopy, the completeness of polypectomy, the patient's general condition, and family and medical history.
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Affiliation(s)
- Dong-Hoon Yang
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
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21
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Baretton GB, Tannapfel A, Schmitt W. [Standardized and structured histopathological evaluation of colorectal polyps: a practical checklist against the background of the new WHO classification]. DER PATHOLOGE 2012; 32:289-96. [PMID: 21678043 DOI: 10.1007/s00292-011-1436-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Gastroenterologists removing colorectal polyps expect standardized and well-structured pathological reports, providing them with all relevant data for the further clinical management of the patient. Over the last year, a task force of clinicians and pathologists has developed a checklist to improve and harmonize endoscopic and pathological reporting of colorectal polyps. This checklist concentrates more on concrete recommendations from evidence-based guidelines and established international classifications for daily practice rather than detailed molecular pathological pathways of carcinogenesis. These recommendations are based on the current S3 guidelines for colorectal cancer (the chapter entitled "Management of colorectal polyps"), the histomorphological consensus manuscript of the GI working group of the German Society for Pathology, as well as the current WHO classification for tumors of the digestive system.
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Affiliation(s)
- G B Baretton
- Institut für Pathologie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
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22
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Abstract
The knowledge that due to the adenoma-cancer sequence polyps will develop sooner or later into invasive cancer demands the complete removal of colorectal polyps. The majority of polyps can be endoscopically removed. The indications for surgical removal of polyps are a previous incomplete endoscopic resection, location not amenable to endoscopic removal and lesions which are macroscopically highly suspicious for malignancy and cannot be detached by submucosal saline injection. If a surgical approach is indicated minimally invasive surgery in the hands of an experienced laparoscopic surgeon is a suitable option. Adenomas suspicious for malignancy in the lower two thirds of the rectum should not be treated by time-consuming endoscopic submucosal dissection (ESD) and can be quickly and safely removed transanally, conventionally or by transanal endoscopic microsurgery (TEM) by a full thickness én bloc resection. This allows the pathologist to determine the depth of invasion and the completeness of resection in terms of the circumferential margin and a definitive radical surgical approach is only necessary in high risk situations.
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Affiliation(s)
- S Rüth
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Klinikum Augsburg, Deutschland.
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23
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Kaltenbach T, Soetikno R. Endoscopic mucosal resection of non-polypoid colorectal neoplasm. Gastrointest Endosc Clin N Am 2010; 20:503-14. [PMID: 20656248 DOI: 10.1016/j.giec.2010.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic mucosal resection (EMR) is preferred to standard polypectomy for the resection of non-polypoid lesions because these lesions can be technically difficult to capture with a snare; furthermore, without submucosal injection the underlying muscularis propria may be excessively coagulated or even inadvertently resected. Because the resection plane of EMR is in the middle or deeper part of the submucosa, EMR allows the precise depth of the lesion to be evaluated. Although the majority of non-polypoid lesions are adenomatous, non-polypoid colorectal neoplasm has a high association with advanced pathology, irrespective of size. Using EMR, a complete pathologic specimen is obtained, the risk of lymph node metastasis can be accurately assessed based on the depth of invasion, and patients can be suitably managed. Used according to its indications, EMR provides curative resection, and obviates the higher morbidity, mortality, and cost associated with surgical treatment.
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Affiliation(s)
- Tonya Kaltenbach
- Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, GI-111, Palo Alto, CA 94304, USA.
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24
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Seo GJ, Sohn DK, Han KS, Hong CW, Kim BC, Park JW, Choi HS, Chang HJ, Oh JH. Recurrence after endoscopic piecemeal mucosal resection for large sessile colorectal polyps. World J Gastroenterol 2010; 16:2806-11. [PMID: 20533602 PMCID: PMC2883138 DOI: 10.3748/wjg.v16.i22.2806] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM: To evaluate the safety and outcomes of endoscopic piecemeal mucosal resection (EPMR) for large sessile colorectal polyps.
METHODS: The patients enrolled in this study were 47 patients with 50 large sessile polyps (diameter, 2 cm or greater) who underwent EPMR using a submucosal saline injection technique between December 2002 and October 2005. All medical records, including characteristics of the patients and polyps, complications, and recurrences, were retrospectively reviewed. The first follow-up endoscopic examination was performed at 3-6 mo after initial endoscopic resection, and the second at 12 mo post-EPMR. Subsequent surveillance colonoscopic examinations were individualized, taking risk factors into account.
RESULTS: The patients were 23 men and 24 women, with a mean age of 60 years. Mean polyp size was 30.1 mm. Of 50 polyps identified, 34 (68%) were benign and 16 (32%) were malignant. There were 6 (12%) cases with EPMR-related bleeding: 5 intra-procedural and 1 early post-procedural bleeding. All bleeding episodes were managed by endoscopic clipping or argon beam coagulation. There were no perforations. Recurrence was identified in 5 cases (12.2%): 4 local recurrences detected at 3 mo post-EPMR and 1 local recurrence detected at 14 mo post-EPMR. The recurrence rate after EPMR was 3.1% for benign polyps and 33.3% for malignant polyps (P < 0.05). Median follow-up time was 37 mo.
CONCLUSION: EPMR is safe, but should be applied carefully in malignant polyps. Close follow-up endoscopic examinations are necessary for early detection of recurrence.
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25
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Soune PA, Ménard C, Salah E, Desjeux A, Grimaud JC, Barthet M. Large endoscopic mucosal resection for colorectal tumors exceeding 4 cm. World J Gastroenterol 2010; 16:588-95. [PMID: 20128027 PMCID: PMC2816271 DOI: 10.3748/wjg.v16.i5.588] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the feasibility and the outcome of endoscopic mucosal resection (EMR) for large colorectal tumors exceeding 4 cm (LCRT) undergoing piecemeal resection.
METHODS: From January 2005 to April 2008, 146 digestive tumors larger than 2 cm were removed with the EMR technique in our department. Of these, 34 tumors were larger than 4 cm and piecemeal resection was carried out on 26 colorectal tumors. The mean age of the patients was 71 years. The mean follow-up duration was 12 mo.
RESULTS: LCRTs were located in the rectum, left colon, transverse colon and right colon in 58%, 15%, 4% and 23% of cases, respectively. All were sessile tumors larger than 4 cm with a mean size of 4.9 cm (4-10 cm). According to the Paris classification, 34% of the tumors were type Is, 58% type IIa, 4% type IIb and 4% type IIc. Pathological examination showed tubulous adenoma in 31%, tubulo-villous adenoma in 27%, villous adenoma in 42%, high-grade dysplasia in 38%, in situ carcinoma in 19% of the cases and mucosal carcinoma (m2) in 8% of the cases. The two cases (7.7%) of procedural bleeding that occurred were managed endoscopically and one small perforation was treated with clips. During follow-up, recurrence of the tumor occurred in three patients (12%), three of whom received endoscopic treatment.
CONCLUSION: EMR for tumors larger than 4 cm is a safe and effective procedure that could compete with endoscopic submucosal dissection, despite providing incomplete histological assessment.
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26
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Salama M, Ormonde D, Quach T, Ee H, Yusoff I. Outcomes of endoscopic resection of large colorectal neoplasms: an Australian experience. J Gastroenterol Hepatol 2010; 25:84-9. [PMID: 19793173 DOI: 10.1111/j.1440-1746.2009.05987.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS Endoscopic resection of large colorectal neoplasms is increasingly being used as an alternative to surgery. However data on failure rates, safety and long-term outcomes remain limited. The aim of the study was to report short- and long-term outcomes from endoscopic resection of large colorectal neoplasms from a single centre and use a model to predict mortality had surgery been performed. METHODS Consecutive patients referred for endoscopic resection of large (> or = 20 mm) colorectal neoplasms from January 2001 to February 2008 were included. Resection details were recorded in a prospectively maintained database. Data was collected on 30-day complication rates, and follow-up colonoscopy findings. The Colorectal-POSSUM score was used to estimate mortality from open surgery. RESULTS There were 154 large neoplasms in 140 patients. Mean age was 68 years (range 22-94). Mean neoplasm size was 26 mm (range 20-80 mm, 24 > or = 40 mm). Complete endoscopic removal was achieved in 95% of cases. Twenty patients were referred for surgery (14%). In the endoscopy group, there were no deaths within 30 days. Twelve patients had a complication including two perforations. Endoscopic follow-up data was available in 90% of cases and five patients (4%) were found to have residual adenoma that was treated endoscopically with subsequent clearance. If surgery had been performed, the mean predicted mortality was 2.2% (range 0.5-10%). There were two deaths (10%) in patients who underwent elective surgery within 30 days. CONCLUSION Endoscopic resection of large colorectal neoplasms is safe and effective even for very large benign neoplasms. When the lesion is endoscopically resectable this should be the preferred treatment.
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Affiliation(s)
- Muna Salama
- Sir Charles Gairdner Hospital, Department of Gastroenterology and Hepatology, Perth, Australia.
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27
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Cipolletta L, Bianco MA, Garofano ML, Cipolleta F, Piscopo R, Rotondano G. Can magnification endoscopy detect residual adenoma after piecemeal resection of large sessile colorectal lesions to guide subsequent treatment? A prospective single-center study. Dis Colon Rectum 2009; 52:1774-9. [PMID: 19966612 DOI: 10.1007/dcr.0b013e3181b5539c] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study assesses the ability of magnification endoscopy to detect residual adenomatous tissue after endoscopic piecemeal resection of colorectal polyps and evaluates the impact of the technique on the incidence of recurrence. METHODS Patients who underwent endoscopic piecemeal resection for large (>2 cm) sessile colorectal polyps were included. After endoscopic piecemeal resection, both the outer resection margins and the central severed area were inspected with magnification endoscopy. Completeness of excision as determined from the magnified surface pattern was compared with that determined histologically. Areas of incomplete resection were treated with additional resection or argon plasma coagulation. RESULTS A total of 77 lesions were resected. Mean size of the resected lesions was 29 +/- 6 mm (range, 23-60). Complications of resection occurred in eight patients (seven had immediate bleeding that was successfully managed with hemoclip application, and one had delayed perforation that was treated surgically). The sensitivity of magnification endoscopy for predicting remnant adenoma at resection margins was 98% (95% confidence interval 90-100); specificity was 90% (95% confidence interval 79-100). Overall accuracy was 94.5% (95% confidence interval 87.2-98.6). On a mean follow-up of 32 months (range, 18-46) the recurrence rate was 2.6%. CONCLUSIONS Magnification endoscopy is accurate at predicting remnant tissue after endoscopic piecemeal resection of large sessile colorectal polypoid lesions. When applied on both outer margins and inner portions of the severed area, it is helpful as a guide to subsequent further treatment to decrease recurrence.
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Affiliation(s)
- Livio Cipolletta
- Division of Gastroenterology and Digestive Endoscopy, Hospital A. Maresca, Torre del Greco, Italy.
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28
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Weinberg DS. Large adenoma recurrence after polypectomy. Gastrointest Endosc 2009; 70:350-2. [PMID: 19631804 DOI: 10.1016/j.gie.2008.12.246] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Accepted: 12/28/2008] [Indexed: 02/08/2023]
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29
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Schäfer H, Baldus SE, Hölscher AH. Giant adenomas of the rectum: complete resection by transanal endoscopic microsurgery (TEM). Int J Colorectal Dis 2006; 21:533-7. [PMID: 16133003 DOI: 10.1007/s00384-005-0025-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2005] [Indexed: 02/04/2023]
Abstract
BACKGROUND Large sessile adenomas of the rectum, with a diameter greater than 5 cm, have a high risk to undergo malignant transformation. Transanal endoscopic microsurgery (TEM) offers an alternative operation method to low-anterior rectum resection in this potentially benign tumor situation. PATIENTS We retrospectively investigated patients with giant adenomas of the rectum (>5 cm) who were treated by TEM over the last 10 years. A total of 33 patients met the criteria and were analyzed for postoperative complications, histology, and incidence of occult adenocarcinoma; residual tumor status; and tumor recurrence. RESULTS Partial suture-line insufficiency (n=5, 15%) was the major postoperative complication, but could be managed conservatively in four cases. The residual adenoma status was 18% (n=6), especially in patients with tumors sizes more than 30 cm2. In case of adenoma recurrence (n=4, 12%), a conventional transanal excision (Parks) was applicable, as these tumors were mostly located within the suture-line region of the lower rectum. Incidentally, five carcinomas were found in the specimens. In case of advanced tumors (1xpT2, 1xpT3), anterior rectum resection was carried out, whereas for the early tumors (2xpT1 low risk, 1x1 pTis), no further therapy was added. All patients (adenomas and carcinomas, n=33) were without recurrence during follow-up. CONCLUSION TEM is an alternative method for the resection of large benign rectal tumors located in the mid- and upper third of the rectum. The main postoperative complication is suture-line insufficiency, which generally heals by conservative treatment.
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Affiliation(s)
- Hartmut Schäfer
- Department of Visceral and Vascular Surgery, University of Cologne, Joseph-Stelzmann Str. 9, 50924 Cologne, Germany.
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30
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Davila RE, Rajan E, Baron TH, Adler DG, Egan JV, Faigel DO, Gan SI, Hirota WK, Leighton JA, Lichtenstein D, Qureshi WA, Shen B, Zuckerman MJ, VanGuilder T, Fanelli RD. ASGE guideline: colorectal cancer screening and surveillance. Gastrointest Endosc 2006; 63:546-57. [PMID: 16564851 DOI: 10.1016/j.gie.2006.02.002] [Citation(s) in RCA: 220] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Raquel E Davila
- American Society for Gastrointestinal Endoscopy, 1520 Kensington Road, Ste. 202, Oak Brook, IL 60523, USA
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31
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Soetikno R, Friedland S, Kaltenbach T, Chayama K, Tanaka S. Nonpolypoid (flat and depressed) colorectal neoplasms. Gastroenterology 2006; 130:566-76; quiz 588-9. [PMID: 16472608 DOI: 10.1053/j.gastro.2005.12.006] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2005] [Accepted: 07/06/2005] [Indexed: 12/17/2022]
Affiliation(s)
- Roy Soetikno
- Veterans Affairs Palo Alto Health Care System, California, USA.
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Loeve F, van Ballegooijen M, Snel P, Habbema JDF. Colorectal cancer risk after colonoscopic polypectomy: a population-based study and literature search. Eur J Cancer 2005; 41:416-22. [PMID: 15691642 DOI: 10.1016/j.ejca.2004.11.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2004] [Revised: 10/25/2004] [Accepted: 11/15/2004] [Indexed: 11/17/2022]
Abstract
Adenoma patients are considered to be at an elevated risk for colorectal cancer, even after their adenomas have been removed. The aim of this study was to estimate the colorectal cancer risk after colonoscopic polypectomy compared with age- and gender-matched general population controls. Colorectal cancer incidence was studied in 553 consecutive patients without cancer whose adenomas were colonoscopically removed in the endoscopy department of a general hospital. The colorectal cancer relative risk in these patients was 0.9 (0.3-2.0). A literature search was performed to identify all published studies on relative colorectal cancer risk after polypectomy. The relative risk estimates in seven other studies ranged from 0.2 (0.1-0.6) to 1.3 (0.6-2.3). The difference can, be explained partially by the inclusion or exclusion of patients with large sessile polyps and other factors. Our review shows that colorectal cancer risk after colonoscopic polypectomy does not exceed the risk in the general population.
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Affiliation(s)
- F Loeve
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, PO Box. 1738, Rotterdam 3000, The Netherlands
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