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Efficacy and Safety of Argon Plasma Coagulation for the Treatment of Hemorrhagic Radiation Proctitis
Abstracts
test performance in screening average-risk population is not known. We aimed to compare the performance characteristics of the reference Guaiac-based FOBT (Hemoccult II) and the qi-FOBT (OC-SENSA) using different positivity cuff-off values for detection of ACRN in average risk population undergoing screening colonoscopy and to determine the number of qi-FOBT needed. Methods: A total of 827 consecutive average-risk patients from four centres who visited to be taken screening colonoscopy also provided the stool samples without dietary restrictions. Stool specimens from 3 consecutive bowel movements were collected and applied on Hemoccult II test card windows and the qi-FOBT sampling probes at the same time. Sensitivity, specificity, positive and negative predictive values, likelihood ratios and 95% CIs of fecal hemoglobin measurements for ACRN, their relationship to the amount of fecal hemoglobin were measured. In addition, the number of qi-FOBTs needed was determined. Results: 78 ACRN (15 cancers and 63 advanced adenomas) were identified during screening colonoscopy. Sensitivity/specificity/positive and negative likelihood ratio/positive and negative predictive values for detecting ACRN by Hemoccult II were 30.7%/83.7%/1.89/0.828/16.2%/92.2%, respectively. Using 3 qiFOBTs and a hemoglobin threshold of 75 and 100 ng/mL, sensitivity/specificity/ positive and negative likelihood ratio/positive and negative predictive values for detecting ACRN were 42.5%/90.1%/4.29/0.64/31.7%/93.5% and 39.0%/91.2%/4.41/ 0.67/31.9%/93.4% respectively. The area under the curve measurements of 1st test, 1st and 2nd tests, and all 3 tests for ACRN were 0.6959, 0.7239, and 0.7379 (pZ0.129), respectively. With threshold of 75 ng/mL and 100 ng/mL, one test of qiFOBT showed similar sensitivity, better specificity, and better positive predictive value for detecting ACRN than 3 sets of Hemoccult II testings. Conclusion: Qi-FOBT provided the better performance characteristics for detecting ACRN in average risk populations than reference Guaiac-based FOBT. Just single testing of qi-FOBT considered to be enough in this population.
T1369 The Clinical and Pathological Features of Depressed Type Colorectal Neoplasms and the Significance of Pit Pattern Diagnosis Shin-Ei Kudo, Orie Takemura, Nobunao Ikehara, Kazuo Ohtsuka, Hiroshi Kashida, Shigeharu Hamatani Introduction: At one time, most colorectal carcinomas were thought to develop from protruded polyps. Recent advances in endoscopic diagnosis and colonoscope technology have revealed the existence of many flat and depressed types of neoplasms. GIE, published in Oct. 2008, widely introduced those lesions as nonpolypoid mucosal colorectal neoplasms (NMCN). We have detected more than 600 depressed type neoplasms at Akita Red Cross Hospital and our Unit during 1985-2008. Depressed type neoplasms are assumed to emerge directly from normal epithelium without going through a stage of adenoma, which is mentioned as the ‘‘de novo’’ carcinogenesis. ‘‘De novo’’ sequence possibly may be main route of development of colorectal cancer. Aim: To evaluate the clinical and pathological natures and validity of pit pattern diagnosis (Kudo’s classification) on depressed type colorectal neoplasms. Methods: From Apr. 2001 to Jun. 2008, we retrospectively evaluated 10,212 colorectal neoplasms, excluding advanced cancers, which removed endoscopically or surgically at our Unit. We evaluated a correlation between submucosal invasive rates and size, morphological features and pit patterns. Result: The submucosal invasive rate of depressed type neoplasms reached 64.1% (98/153). Meanwhile, the overall invasive rates of flat and protruded type neoplasms were 2.6% (98/3772) and 3.2% (204/6288), respectively. The submucosal invasive rates were 6.5% in lesions not exceeding 5 mm, 60.8% in those from 6-10 mm, and 89.2% in those from 11-15 mm in diameter. In contrast, the invasive rates in flat type and protruded type neoplasms were 0% and 0.04% for those less than 5mm in diameter. Most (90.9% and 91.7%) of the protruded and flat type neoplasms showed type IIIL or IV pit patterns, whereas 94.3% of the depressed type neoplasms were characterized by type IIIS, VI, or VN pit patterns. Only 0.63% of the lesions with type IIIL, and IV pit patterns were invasive cancers. On the other hand, 2.4% of the lesions with type IIIS pit pattern, 34.5% of those of type VI and 91.1% of those of type VN were invasive carcinomas regardless of its gross appearance. Type VI reflected histological structural atypism outgrowth of cancerous glands, and type VN, which lacks of superficial microstructure, reflected exposing desmoplastic reaction of deeply invasive submucosal components to the surface. Conclusion: We have revealed that depressed type neoplasms grow rapidly and invade the submucosa even at an early stage. With magnifying colonoscopies, the pit pattern diagnosis, which correlated well with the histological diagnosis, is available for assessing the depth of the lesions and selecting appropriate therapies.
T1370 Comparison of Endoscopic Submucosal Dissection (ESD) Using Sodium Hyaluronate and Needle-Knife Versus Endoscopic Mucosal Resection (EMR) for Laterally Spreading Tumor (LST) of the Colon Ayako Okuda, Makoto Nishimura, Hideki Kitada, Shuya Yoshinaga, Kouichi Nonaka, Michio Hifumi
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Background and Aims: Since en-bloc resection by endoscopic submucosal dissection (ESD) facilitates an accurate histological evaluation, this technique has been developed to treat GI tract lesions. The ESD method using sodium hyaluronate and a needle-knife was applied for lateral spreading tumors (LST) of the colorectum. This study compared outcomes between ESD and EMR for colorectal LST treated at our institution. Methods: Between July 2004 and July 2008, we treated 106 patients (66 males/40 females; mean age: 67.3 years, range 40-84 years) with LST by ESD or EMR at our institution. The size of the resected specimen, en-bloc resection rate, negative horizontal margin rate, complications, and histopathological findings were analyzed and compared between the ESD group and EMR group. Results: In this study, ESD was performed on 60 patients, and EMR was performed on 46 patients. The mean resected specimen size was 29.1mm (range 10-65 mm in diameter) for ESD and 18.2mm (range 10-55 mm in diameter) for EMR (p!0.01). The en-bloc rate was 90.0% with ESD and 71.7% with EMR (p!0.01). Histopathologically, there were 3 carcinomas,13 carcinomas in adenoma and 41 adenomas in the ESD group, and 1 carcinoma, 6 carcinomas in adenoma and 34 adenomas in the EMR group. The negative horizontal margin rate was 73.3% for ESD and 67.3% for EMR (p!0.01). Three cases undergoing ESD and two cases undergoing EMR demonstrated a significant quantity of active bleeding during the procedure, but endoscopic hemostasis was successful in all cases. Conclusions: Our results indicate that ESD using sodium hyaluronate and needleknife is feasible for colorectal LST without any greater risk than the EMR technique. Therefore, we conclude that our ESD method might be a more reliable treatment for colorectal LST than EMR.
T1371 Effectiveness of Endoscopic Submucosal Dissection As An Alternative to Traditional Surgery for Large Lateral Spreading Polyps and Early Malignancies of the Colon and Rectum in the United States Mainor R. Antillon, Wilson P. Pais, Alberto A. Diaz-Arias, Seema S. Tekwani, Jamal A. Ibdah, John B. Marshall Background: Endoscopic submucosal dissection (ESD), a type of intraluminal endoscopic surgery, was developed in Japan for en-bloc removal of GI tumors as an alternative to conventional surgical removal. The technique employs an electrosurgical knife to dissect the submucosal layer beneath the lesion, and is capable of removing en-bloc (one piece) much larger tumors than the older technique of endoscopic mucosal resection. Though initially done for gastric tumors, ESD has now been applied to lesions elsewhere in the gut. There is little published experience with ESD outside of Asia. Objective: Our purpose was to assess the effectiveness and safety of ESD for the removal of large lateral spreading polyps and early malignancies at our American academic med center. Methods: Retrospective analysis from chart audits of 86 consecutive patients who underwent colorectal ESD between June 2006 and November 2008. All procedures were performed by one endoscopist (MRA). Results: There were 63 colonic and 23 rectal lesions. Of the latter, 10 extended to the anal canal. Seventy of the colorectal lesions were benign adenomas and 16 contained cancer. The mean size of lesions was 4.2-cm (range, 1.5- to 14-cm). Procedural success was 100%. The rate of en-bloc resection was 86.0% (74/86), and en-bloc resection with tumor-free lateral/basal margins was 62.8% (54/86). All tumors which extended to the dentate line were successfully removed, avoided the need for colostomy, and continence was preserved. The complications in our series included perforations in 5.8% (5/86). Surgery was performed in 3, including two early in our experience. The other two were medically managed. Bleeding was seen in 3.5% (3/86). Two required 2 units of packed RBCs each; no other therapy was needed. Mean length of hospitalization was 1.3 days. We are in the process of collecting long-term outcome data. To this point, only one patient with a benign lesion was found to have residual polyp tissue at the time of follow-up endoscopy. It was successfully ablated, and subsequent endoscopy has not disclosed recurrence. Five of the patients with malignancies had sm deep cancers for which surgery was recommended. The other cancers, intramucosal cancers and minute sm cancers, have not shown recurrences to this point. Conclusions: ESD performed at our American center shows promising results for removal of lateral spreading colorectal polyps and early cancers as an alternative to surgical removal. En-bloc removal also allows the pathologist to better assess for invasive cancer compared to piecemeal polypectomy. ESD is also applicable when there is rectal involvement to the dentate line.
T1372 Efficacy and Safety of Argon Plasma Coagulation for the Treatment of Hemorrhagic Radiation Proctitis Paulo Correa, Eduardo J. Lobo, Marcelo Averbach, Jose Paccos, Giulio F. Rossini, Oswaldo W. Marques, Pedro Popoutchi Background: Radiation proctitis is the most relevant complication of radiotherapy for malignant pelvic disease and occurs in about 5% to 10% of all patients. It is characterized by bleeding, rectal pain, diarrhea, mucoid discharge and fecal urgency. There is no consensus for the management of this condition and many conservative treatment modalities have been proposed with varying success. Argon
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB279
Abstracts
plasma coagulation is an effective treatment for hemorrhagic lesions of the gastrointestinal tract. Aim: The aim of this study is to assess the efficacy and safety of argon plasma coagulation (APC) applied endoscopically to treat hemorrhagic radiation proctitis (HRP). Methods: Forty-six patients (34 males with prostate cancer) underwent endoscopic treatment in Sı´rio Libaneˆs Hospital using argon plasma coagulation for HRP between December 1997 and February 2008. Nine of them lost attendance and was excluded of this study. The mean age was 68 years (range 40 to 86 years). The onset of the symptoms were 3 to 84 months after the conclusion of radiotherapy. A clinical scale (Chutkan) was used to assess bleeding before and after treatment. All patients were submitted to an anterograde bowel preparation. APC was applied with a flow rate of argon gas of 1.5 to 2.5 l/min and a power setting of 60W. Consecutive treatment sessions were programmed whenever it was considered necessary. Results: Eight-six sessions were performed in 46 patients. The mean number of treatment sessions to stop symptoms was 1.87 per patient. Forty-six percent of the patients had improvement in rectal bleeding after one session and 35% after the second session. Just one major complication occurred, a massive bleeding after APC session that required blood transfusion. The tolerance was good, with no long-term treatment-related complications. Conclusions: APC is an effective and safe treatment for rectal bleeding caused by radiation proctitis.
T1373 Endoscopic Management of Large Colorectal Polyps Referred for Surgical Resection Satish Nagula, Alexander Weiss, Martin R. Weiser, Mark A. Schattner Background: Large colorectal polyps (O 2 cm) have a high incidence of high grade dysplasia (HGD) and carry a high risk of transforming into an adenocarcinoma. Large polyps are often referred for surgical resection due to technical difficulties in endoscopic management. The role of repeat endoscopic polypectomy by a tertiarylevel gastroenterologist prior to surgery has not been clearly established. Methods: We identified 77 patients in a retrospective review at Memorial Sloan-Kettering Cancer Center that were referred to the Colorectal Surgery Service between 2003 and 2008 with a diagnosis of benign colon or rectal polyp (ICD-9: 211.3 or 211.4) who underwent a subsequent colonoscopy with possible polypectomy by the Gastroenterology Service within 3 months. The patient demographics, polyp characteristics, outcome of endoscopic and surgical management (if necessary), and procedural complications were recorded. Results: Of these 77 patients, 50 (65%) underwent endoscopic polypectomy (average duration: 49 minutes [range 7-84 minutes]; average polyp size: 2.9 cm [range 1-8cm]). Pathology revealed 6 adenocarcinomas, 5 intramucosal adenocarcinomas, 9 adenomas with HGD, 26 adenomas, and 4 hyperplastic polyps. Thirty-four of these 50 patients had a followup colonoscopy: 12 (35%) required repeat polypectomy; 20 (59%) had no residual polyp; 2 patients had malignant appearing lesions requiring surgery. Twenty-seven patients (35%) had polyps not amenable for endoscopic polypectomy (average polyp size: 3.5 cm [range 1.5-6 cm]): 13 with polyps too large to be managed endoscopically, 10 with difficult anatomy or polyp location, and 8 with infiltrative appearing polyps that could not be raised with saline injection (some patients included twice). Twenty of these patients proceeded with surgery; 9 via laparoscopy. Pathology revealed 8 patients with adenocarcinoma and 8 patients with adenomatous polyps with HGD. Median length of the stay after surgery was 6 days (range 4-57 days). Seven patients (35%) developed post-surgical complications: 3 with protracted ileus, 1 with an anastomotic leak, 1 with an abscess, 1 with congestive heart failure, and 1 developed a ventral hernia. Two patients had bleeding after colonoscopy, 1 requiring a 24 hour hospital admission without need for transfusions; no other complications were seen after colonoscopy. Conclusion: A significant percentage of patients with large colorectal polyps referred for surgical management can be safely managed by a tertiary-level gastroenterologist, avoiding the need for surgical resection. Patients must undergo close surveillance to ensure complete polypectomy and to eradicate recurrent polyps.
T1374 Endoscopic Submucosal Dissection for Colorectal Tumor Larger Than 10mm: Single Center Experience Kwangbum Cho, Byoungkuk Jang, Woo Jin Chung, Kyung Sik Park, Jaeseok Hwang Background: ESD is a novel technique that can facilitate en-bloc resection and has been positively applied to and gradually standardized for early gastric cancer. However, the reports about ESD for colorectal tumor are scanty, because it is technically difficult to perform ESD of the colon. Aim: To evaluate the efficacy of endoscopic submucosal dissection (ESD) for colorectal tumor larger than 10mm in single center experience. Methods: A total of 50 consecutive patients (53 lesions) underwent colorectal ESD from Mar 2007 to Aug 2008. Time required for ESD, rate of complete en bloc resection, complication, and postoperative local persistence and recurrence were investigated retrospectively. Results: The average time
AB280 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
required for ESD was 79.944 minutes (range, 20-180 minutes), and the histologic rate of complete en bloc resection was 66% (35/53). 18 lesions (34%) were removed by piecemeally after en-bloc failure. Mean size of specimen is 27.9 13.4 mm (10-90mm). With regard to complication, 11.3% of cases of postoperative hemorrhage (6/53) and 24.5% of cases of perforation (13/53) were observed in total. The hospital stay is elongated at the complicated patients (the normal and perforated cases: 3.6 days vs. 6.1 days, pZ0.012). Nine out of 26 adenocarcinoma lesions (49.1%) were revealed upper one thrd submucosal invasion. One patient with angiolymphatic invasion after ESD was further treated by surgical resection. Average duration of follow-up was 289 269 days, and no case of local persistence and recurrence or metastasis was observed. Conclusions: With regard to ESD of the colon, complication, eg, perforation, could be managed medically successfully. ESD is a feasible technique for treating superficial colorectal tumors and precancerous lesion.
T1375 Learning Curve of Endoscopic Submucosal Dissection for Colorectal Tumors Kinichi Hotta, Tsuneo Oyama Background and Aim: Endoscopic submucosal dissection (ESD) for large colorectal tumors has been developed recently in Japan. However, its technical difficulty and the high risk of complications disturb its standardization. This study is designed to clarify the learning curve of ESD for colorectal tumors by a single colonoscopist and to present the target number of cases to acquire the skill. Methods: A total of 120 colorectal tumors in 115 patients (68 males and 47 females with the median age at 70) were treated by ESD in our hospital between June 2003 and September 2008. All the procedures were performed by an experienced colonoscopist (K.H.). All of them were evenly classified into 3 periods (1st: 1-40, 2nd: 41-80, and 3rd: 81-120). Clinicopathological features, procedure time per square measure (minutes/cm2), the en-bloc resection rate, the en-bloc and R0 resection rate, and the perforation rate. Hook knife and flex knife were mainly used for mucosal incision and submucosal dissection. Sodium hyaluronate was used for submucosal injection. Informed consent was secured from all patients before treatment. Results: Locations (cecum/ascending/transverse/descending/sigmoid/rectum) were 5/11/8/1/ 2/13 in the 1st, 10/6/8/0/5/11 in the 2nd and 10/7/7/2/5/9 in the 3rd periods. Macroscopic types (LST-G: laterally spreading tumor granular type/LST-NG: laterally spreading tumor non-granular type/miscellaneous) were 21/15/4 in the 1st, 29/11/ 0 in the 2nd and 22/17/1 in the 3rd periods. Pathological types (adenoma/ intramucosal cancer/submucosal invasive cancer) were 18/18/4 in the 1st, 15/21/4 in the 2nd, and 14/16/10 in the 3rd periods. The mean tumor sizes (mm) were 31.3 in the 1st, 40.2 in the 2nd and 33.2 in the 3rd periods. The procedure times per square measure (minutes/cm2) were 14.8 in the 1st, 9.9 (P!0.05) in the 2nd and 10.1 (P!0.05) in the 3rd periods. The en-bloc resection rates were 92.5% in the 1st, 90% in the 2nd and 97.5% in the 3rd periods (n.s.). The en-bloc and R0 resection rates were 85% in the 1st, 77.5% in the 2nd and 92.5% in the 3rd periods (n.s.). The perforation rates were 12.5% (5/40) in the 1st, 5% (2/40) in the 2nd and 5% (2/40) in the 3rd periods (n.s.). Only one patient underwent emergent surgery due to perforation in the 2nd period. Conclusions: Based on our analysis of the learning curve, the procedure time was significantly shortened after the 2nd period. The perforations tend to decrease after the 2nd period. The en-bloc and R0 resection rate tends to improve after the 3rd period. The number of cases to require the ESD skill for large colorectal tumors was about 80.
T1376 Long Term Follow-Up in a Large Series of Patients with Chronic Radiation Induced Proctitis Treated By Argon Plasma Coagulation Monica Pandolfi, Margareth Martino, Alessandra Bizzotto, Roberta Rea, Guido Costamagna, Lucio Petruzziello Background: Radiation Proctitis (RP) is a well-know complication of radiotherapy for malignant pelvic diseases. Anemia and rectal bleeding represent the most common symptoms in these patients. Argon Plasma Coagulation (APC) is considered as an effective therapeutic option for this condition. The efficacy of this treatment has not been evaluated in large series with long-term follow-up. The aim of the study is to evaluate the outcomes of APC treatment in a large consecutive series of patients affected by RP, with a long-term follow-up. Patients and Methods: The study included 67 patients (57 men, mean age 71 years, range 39-86 years) with RP, who underwent APC treatment between 2000 and 2008. All patients presented with rectal bleeding. Patients were treated with ERBE APC Systems (3,2 mm probe, gas flow 1-2 l/min; power range: 25W-60W) after standard bowel preparation. Success was defined either as cessation or a significant reduction in bleeding not requiring further treatment. Results: Seven patients are still under treatment. Sixty patients completed the treatment: 18 (30%) in a single session and 42 (70%) with multiple sessions (mean 3.5, range 2-5). All patients are asymptomatic at a median follow up of 48.5 months (range 12-96). Anemia improved in all patients. Complication rate was 8.3% (including 2 symptomatic chronic ulcers, 2 rectal strictures and 1 post-procedure fever). One patient with rectal stricture was successfully treated with mechanical rectal dilation. All APC sessions were well
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test performance in screening average-risk population is not known. We aimed to compare the performance characteristics of the reference Guaiac-based FOBT (Hemoccult II) and the qi-FOBT (OC-SENSA) using different positivity cuff-off values for detection of ACRN in average risk population undergoing screening colonoscopy and to determine the number of qi-FOBT needed. Methods: A total of 827 consecutive average-risk patients from four centres who visited to be taken screening colonoscopy also provided the stool samples without dietary restrictions. Stool specimens from 3 consecutive bowel movements were collected and applied on Hemoccult II test card windows and the qi-FOBT sampling probes at the same time. Sensitivity, specificity, positive and negative predictive values, likelihood ratios and 95% CIs of fecal hemoglobin measurements for ACRN, their relationship to the amount of fecal hemoglobin were measured. In addition, the number of qi-FOBTs needed was determined. Results: 78 ACRN (15 cancers and 63 advanced adenomas) were identified during screening colonoscopy. Sensitivity/specificity/positive and negative likelihood ratio/positive and negative predictive values for detecting ACRN by Hemoccult II were 30.7%/83.7%/1.89/0.828/16.2%/92.2%, respectively. Using 3 qiFOBTs and a hemoglobin threshold of 75 and 100 ng/mL, sensitivity/specificity/ positive and negative likelihood ratio/positive and negative predictive values for detecting ACRN were 42.5%/90.1%/4.29/0.64/31.7%/93.5% and 39.0%/91.2%/4.41/ 0.67/31.9%/93.4% respectively. The area under the curve measurements of 1st test, 1st and 2nd tests, and all 3 tests for ACRN were 0.6959, 0.7239, and 0.7379 (pZ0.129), respectively. With threshold of 75 ng/mL and 100 ng/mL, one test of qiFOBT showed similar sensitivity, better specificity, and better positive predictive value for detecting ACRN than 3 sets of Hemoccult II testings. Conclusion: Qi-FOBT provided the better performance characteristics for detecting ACRN in average risk populations than reference Guaiac-based FOBT. Just single testing of qi-FOBT considered to be enough in this population.
T1369 The Clinical and Pathological Features of Depressed Type Colorectal Neoplasms and the Significance of Pit Pattern Diagnosis Shin-Ei Kudo, Orie Takemura, Nobunao Ikehara, Kazuo Ohtsuka, Hiroshi Kashida, Shigeharu Hamatani Introduction: At one time, most colorectal carcinomas were thought to develop from protruded polyps. Recent advances in endoscopic diagnosis and colonoscope technology have revealed the existence of many flat and depressed types of neoplasms. GIE, published in Oct. 2008, widely introduced those lesions as nonpolypoid mucosal colorectal neoplasms (NMCN). We have detected more than 600 depressed type neoplasms at Akita Red Cross Hospital and our Unit during 1985-2008. Depressed type neoplasms are assumed to emerge directly from normal epithelium without going through a stage of adenoma, which is mentioned as the ‘‘de novo’’ carcinogenesis. ‘‘De novo’’ sequence possibly may be main route of development of colorectal cancer. Aim: To evaluate the clinical and pathological natures and validity of pit pattern diagnosis (Kudo’s classification) on depressed type colorectal neoplasms. Methods: From Apr. 2001 to Jun. 2008, we retrospectively evaluated 10,212 colorectal neoplasms, excluding advanced cancers, which removed endoscopically or surgically at our Unit. We evaluated a correlation between submucosal invasive rates and size, morphological features and pit patterns. Result: The submucosal invasive rate of depressed type neoplasms reached 64.1% (98/153). Meanwhile, the overall invasive rates of flat and protruded type neoplasms were 2.6% (98/3772) and 3.2% (204/6288), respectively. The submucosal invasive rates were 6.5% in lesions not exceeding 5 mm, 60.8% in those from 6-10 mm, and 89.2% in those from 11-15 mm in diameter. In contrast, the invasive rates in flat type and protruded type neoplasms were 0% and 0.04% for those less than 5mm in diameter. Most (90.9% and 91.7%) of the protruded and flat type neoplasms showed type IIIL or IV pit patterns, whereas 94.3% of the depressed type neoplasms were characterized by type IIIS, VI, or VN pit patterns. Only 0.63% of the lesions with type IIIL, and IV pit patterns were invasive cancers. On the other hand, 2.4% of the lesions with type IIIS pit pattern, 34.5% of those of type VI and 91.1% of those of type VN were invasive carcinomas regardless of its gross appearance. Type VI reflected histological structural atypism outgrowth of cancerous glands, and type VN, which lacks of superficial microstructure, reflected exposing desmoplastic reaction of deeply invasive submucosal components to the surface. Conclusion: We have revealed that depressed type neoplasms grow rapidly and invade the submucosa even at an early stage. With magnifying colonoscopies, the pit pattern diagnosis, which correlated well with the histological diagnosis, is available for assessing the depth of the lesions and selecting appropriate therapies.
T1370 Comparison of Endoscopic Submucosal Dissection (ESD) Using Sodium Hyaluronate and Needle-Knife Versus Endoscopic Mucosal Resection (EMR) for Laterally Spreading Tumor (LST) of the Colon Ayako Okuda, Makoto Nishimura, Hideki Kitada, Shuya Yoshinaga, Kouichi Nonaka, Michio Hifumi
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Background and Aims: Since en-bloc resection by endoscopic submucosal dissection (ESD) facilitates an accurate histological evaluation, this technique has been developed to treat GI tract lesions. The ESD method using sodium hyaluronate and a needle-knife was applied for lateral spreading tumors (LST) of the colorectum. This study compared outcomes between ESD and EMR for colorectal LST treated at our institution. Methods: Between July 2004 and July 2008, we treated 106 patients (66 males/40 females; mean age: 67.3 years, range 40-84 years) with LST by ESD or EMR at our institution. The size of the resected specimen, en-bloc resection rate, negative horizontal margin rate, complications, and histopathological findings were analyzed and compared between the ESD group and EMR group. Results: In this study, ESD was performed on 60 patients, and EMR was performed on 46 patients. The mean resected specimen size was 29.1mm (range 10-65 mm in diameter) for ESD and 18.2mm (range 10-55 mm in diameter) for EMR (p!0.01). The en-bloc rate was 90.0% with ESD and 71.7% with EMR (p!0.01). Histopathologically, there were 3 carcinomas,13 carcinomas in adenoma and 41 adenomas in the ESD group, and 1 carcinoma, 6 carcinomas in adenoma and 34 adenomas in the EMR group. The negative horizontal margin rate was 73.3% for ESD and 67.3% for EMR (p!0.01). Three cases undergoing ESD and two cases undergoing EMR demonstrated a significant quantity of active bleeding during the procedure, but endoscopic hemostasis was successful in all cases. Conclusions: Our results indicate that ESD using sodium hyaluronate and needleknife is feasible for colorectal LST without any greater risk than the EMR technique. Therefore, we conclude that our ESD method might be a more reliable treatment for colorectal LST than EMR.
T1371 Effectiveness of Endoscopic Submucosal Dissection As An Alternative to Traditional Surgery for Large Lateral Spreading Polyps and Early Malignancies of the Colon and Rectum in the United States Mainor R. Antillon, Wilson P. Pais, Alberto A. Diaz-Arias, Seema S. Tekwani, Jamal A. Ibdah, John B. Marshall Background: Endoscopic submucosal dissection (ESD), a type of intraluminal endoscopic surgery, was developed in Japan for en-bloc removal of GI tumors as an alternative to conventional surgical removal. The technique employs an electrosurgical knife to dissect the submucosal layer beneath the lesion, and is capable of removing en-bloc (one piece) much larger tumors than the older technique of endoscopic mucosal resection. Though initially done for gastric tumors, ESD has now been applied to lesions elsewhere in the gut. There is little published experience with ESD outside of Asia. Objective: Our purpose was to assess the effectiveness and safety of ESD for the removal of large lateral spreading polyps and early malignancies at our American academic med center. Methods: Retrospective analysis from chart audits of 86 consecutive patients who underwent colorectal ESD between June 2006 and November 2008. All procedures were performed by one endoscopist (MRA). Results: There were 63 colonic and 23 rectal lesions. Of the latter, 10 extended to the anal canal. Seventy of the colorectal lesions were benign adenomas and 16 contained cancer. The mean size of lesions was 4.2-cm (range, 1.5- to 14-cm). Procedural success was 100%. The rate of en-bloc resection was 86.0% (74/86), and en-bloc resection with tumor-free lateral/basal margins was 62.8% (54/86). All tumors which extended to the dentate line were successfully removed, avoided the need for colostomy, and continence was preserved. The complications in our series included perforations in 5.8% (5/86). Surgery was performed in 3, including two early in our experience. The other two were medically managed. Bleeding was seen in 3.5% (3/86). Two required 2 units of packed RBCs each; no other therapy was needed. Mean length of hospitalization was 1.3 days. We are in the process of collecting long-term outcome data. To this point, only one patient with a benign lesion was found to have residual polyp tissue at the time of follow-up endoscopy. It was successfully ablated, and subsequent endoscopy has not disclosed recurrence. Five of the patients with malignancies had sm deep cancers for which surgery was recommended. The other cancers, intramucosal cancers and minute sm cancers, have not shown recurrences to this point. Conclusions: ESD performed at our American center shows promising results for removal of lateral spreading colorectal polyps and early cancers as an alternative to surgical removal. En-bloc removal also allows the pathologist to better assess for invasive cancer compared to piecemeal polypectomy. ESD is also applicable when there is rectal involvement to the dentate line.
T1372 Efficacy and Safety of Argon Plasma Coagulation for the Treatment of Hemorrhagic Radiation Proctitis Paulo Correa, Eduardo J. Lobo, Marcelo Averbach, Jose Paccos, Giulio F. Rossini, Oswaldo W. Marques, Pedro Popoutchi Background: Radiation proctitis is the most relevant complication of radiotherapy for malignant pelvic disease and occurs in about 5% to 10% of all patients. It is characterized by bleeding, rectal pain, diarrhea, mucoid discharge and fecal urgency. There is no consensus for the management of this condition and many conservative treatment modalities have been proposed with varying success. Argon
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB279
Abstracts
plasma coagulation is an effective treatment for hemorrhagic lesions of the gastrointestinal tract. Aim: The aim of this study is to assess the efficacy and safety of argon plasma coagulation (APC) applied endoscopically to treat hemorrhagic radiation proctitis (HRP). Methods: Forty-six patients (34 males with prostate cancer) underwent endoscopic treatment in Sı´rio Libaneˆs Hospital using argon plasma coagulation for HRP between December 1997 and February 2008. Nine of them lost attendance and was excluded of this study. The mean age was 68 years (range 40 to 86 years). The onset of the symptoms were 3 to 84 months after the conclusion of radiotherapy. A clinical scale (Chutkan) was used to assess bleeding before and after treatment. All patients were submitted to an anterograde bowel preparation. APC was applied with a flow rate of argon gas of 1.5 to 2.5 l/min and a power setting of 60W. Consecutive treatment sessions were programmed whenever it was considered necessary. Results: Eight-six sessions were performed in 46 patients. The mean number of treatment sessions to stop symptoms was 1.87 per patient. Forty-six percent of the patients had improvement in rectal bleeding after one session and 35% after the second session. Just one major complication occurred, a massive bleeding after APC session that required blood transfusion. The tolerance was good, with no long-term treatment-related complications. Conclusions: APC is an effective and safe treatment for rectal bleeding caused by radiation proctitis.
T1373 Endoscopic Management of Large Colorectal Polyps Referred for Surgical Resection Satish Nagula, Alexander Weiss, Martin R. Weiser, Mark A. Schattner Background: Large colorectal polyps (O 2 cm) have a high incidence of high grade dysplasia (HGD) and carry a high risk of transforming into an adenocarcinoma. Large polyps are often referred for surgical resection due to technical difficulties in endoscopic management. The role of repeat endoscopic polypectomy by a tertiarylevel gastroenterologist prior to surgery has not been clearly established. Methods: We identified 77 patients in a retrospective review at Memorial Sloan-Kettering Cancer Center that were referred to the Colorectal Surgery Service between 2003 and 2008 with a diagnosis of benign colon or rectal polyp (ICD-9: 211.3 or 211.4) who underwent a subsequent colonoscopy with possible polypectomy by the Gastroenterology Service within 3 months. The patient demographics, polyp characteristics, outcome of endoscopic and surgical management (if necessary), and procedural complications were recorded. Results: Of these 77 patients, 50 (65%) underwent endoscopic polypectomy (average duration: 49 minutes [range 7-84 minutes]; average polyp size: 2.9 cm [range 1-8cm]). Pathology revealed 6 adenocarcinomas, 5 intramucosal adenocarcinomas, 9 adenomas with HGD, 26 adenomas, and 4 hyperplastic polyps. Thirty-four of these 50 patients had a followup colonoscopy: 12 (35%) required repeat polypectomy; 20 (59%) had no residual polyp; 2 patients had malignant appearing lesions requiring surgery. Twenty-seven patients (35%) had polyps not amenable for endoscopic polypectomy (average polyp size: 3.5 cm [range 1.5-6 cm]): 13 with polyps too large to be managed endoscopically, 10 with difficult anatomy or polyp location, and 8 with infiltrative appearing polyps that could not be raised with saline injection (some patients included twice). Twenty of these patients proceeded with surgery; 9 via laparoscopy. Pathology revealed 8 patients with adenocarcinoma and 8 patients with adenomatous polyps with HGD. Median length of the stay after surgery was 6 days (range 4-57 days). Seven patients (35%) developed post-surgical complications: 3 with protracted ileus, 1 with an anastomotic leak, 1 with an abscess, 1 with congestive heart failure, and 1 developed a ventral hernia. Two patients had bleeding after colonoscopy, 1 requiring a 24 hour hospital admission without need for transfusions; no other complications were seen after colonoscopy. Conclusion: A significant percentage of patients with large colorectal polyps referred for surgical management can be safely managed by a tertiary-level gastroenterologist, avoiding the need for surgical resection. Patients must undergo close surveillance to ensure complete polypectomy and to eradicate recurrent polyps.
T1374 Endoscopic Submucosal Dissection for Colorectal Tumor Larger Than 10mm: Single Center Experience Kwangbum Cho, Byoungkuk Jang, Woo Jin Chung, Kyung Sik Park, Jaeseok Hwang Background: ESD is a novel technique that can facilitate en-bloc resection and has been positively applied to and gradually standardized for early gastric cancer. However, the reports about ESD for colorectal tumor are scanty, because it is technically difficult to perform ESD of the colon. Aim: To evaluate the efficacy of endoscopic submucosal dissection (ESD) for colorectal tumor larger than 10mm in single center experience. Methods: A total of 50 consecutive patients (53 lesions) underwent colorectal ESD from Mar 2007 to Aug 2008. Time required for ESD, rate of complete en bloc resection, complication, and postoperative local persistence and recurrence were investigated retrospectively. Results: The average time
AB280 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
required for ESD was 79.944 minutes (range, 20-180 minutes), and the histologic rate of complete en bloc resection was 66% (35/53). 18 lesions (34%) were removed by piecemeally after en-bloc failure. Mean size of specimen is 27.9 13.4 mm (10-90mm). With regard to complication, 11.3% of cases of postoperative hemorrhage (6/53) and 24.5% of cases of perforation (13/53) were observed in total. The hospital stay is elongated at the complicated patients (the normal and perforated cases: 3.6 days vs. 6.1 days, pZ0.012). Nine out of 26 adenocarcinoma lesions (49.1%) were revealed upper one thrd submucosal invasion. One patient with angiolymphatic invasion after ESD was further treated by surgical resection. Average duration of follow-up was 289 269 days, and no case of local persistence and recurrence or metastasis was observed. Conclusions: With regard to ESD of the colon, complication, eg, perforation, could be managed medically successfully. ESD is a feasible technique for treating superficial colorectal tumors and precancerous lesion.
T1375 Learning Curve of Endoscopic Submucosal Dissection for Colorectal Tumors Kinichi Hotta, Tsuneo Oyama Background and Aim: Endoscopic submucosal dissection (ESD) for large colorectal tumors has been developed recently in Japan. However, its technical difficulty and the high risk of complications disturb its standardization. This study is designed to clarify the learning curve of ESD for colorectal tumors by a single colonoscopist and to present the target number of cases to acquire the skill. Methods: A total of 120 colorectal tumors in 115 patients (68 males and 47 females with the median age at 70) were treated by ESD in our hospital between June 2003 and September 2008. All the procedures were performed by an experienced colonoscopist (K.H.). All of them were evenly classified into 3 periods (1st: 1-40, 2nd: 41-80, and 3rd: 81-120). Clinicopathological features, procedure time per square measure (minutes/cm2), the en-bloc resection rate, the en-bloc and R0 resection rate, and the perforation rate. Hook knife and flex knife were mainly used for mucosal incision and submucosal dissection. Sodium hyaluronate was used for submucosal injection. Informed consent was secured from all patients before treatment. Results: Locations (cecum/ascending/transverse/descending/sigmoid/rectum) were 5/11/8/1/ 2/13 in the 1st, 10/6/8/0/5/11 in the 2nd and 10/7/7/2/5/9 in the 3rd periods. Macroscopic types (LST-G: laterally spreading tumor granular type/LST-NG: laterally spreading tumor non-granular type/miscellaneous) were 21/15/4 in the 1st, 29/11/ 0 in the 2nd and 22/17/1 in the 3rd periods. Pathological types (adenoma/ intramucosal cancer/submucosal invasive cancer) were 18/18/4 in the 1st, 15/21/4 in the 2nd, and 14/16/10 in the 3rd periods. The mean tumor sizes (mm) were 31.3 in the 1st, 40.2 in the 2nd and 33.2 in the 3rd periods. The procedure times per square measure (minutes/cm2) were 14.8 in the 1st, 9.9 (P!0.05) in the 2nd and 10.1 (P!0.05) in the 3rd periods. The en-bloc resection rates were 92.5% in the 1st, 90% in the 2nd and 97.5% in the 3rd periods (n.s.). The en-bloc and R0 resection rates were 85% in the 1st, 77.5% in the 2nd and 92.5% in the 3rd periods (n.s.). The perforation rates were 12.5% (5/40) in the 1st, 5% (2/40) in the 2nd and 5% (2/40) in the 3rd periods (n.s.). Only one patient underwent emergent surgery due to perforation in the 2nd period. Conclusions: Based on our analysis of the learning curve, the procedure time was significantly shortened after the 2nd period. The perforations tend to decrease after the 2nd period. The en-bloc and R0 resection rate tends to improve after the 3rd period. The number of cases to require the ESD skill for large colorectal tumors was about 80.
T1376 Long Term Follow-Up in a Large Series of Patients with Chronic Radiation Induced Proctitis Treated By Argon Plasma Coagulation Monica Pandolfi, Margareth Martino, Alessandra Bizzotto, Roberta Rea, Guido Costamagna, Lucio Petruzziello Background: Radiation Proctitis (RP) is a well-know complication of radiotherapy for malignant pelvic diseases. Anemia and rectal bleeding represent the most common symptoms in these patients. Argon Plasma Coagulation (APC) is considered as an effective therapeutic option for this condition. The efficacy of this treatment has not been evaluated in large series with long-term follow-up. The aim of the study is to evaluate the outcomes of APC treatment in a large consecutive series of patients affected by RP, with a long-term follow-up. Patients and Methods: The study included 67 patients (57 men, mean age 71 years, range 39-86 years) with RP, who underwent APC treatment between 2000 and 2008. All patients presented with rectal bleeding. Patients were treated with ERBE APC Systems (3,2 mm probe, gas flow 1-2 l/min; power range: 25W-60W) after standard bowel preparation. Success was defined either as cessation or a significant reduction in bleeding not requiring further treatment. Results: Seven patients are still under treatment. Sixty patients completed the treatment: 18 (30%) in a single session and 42 (70%) with multiple sessions (mean 3.5, range 2-5). All patients are asymptomatic at a median follow up of 48.5 months (range 12-96). Anemia improved in all patients. Complication rate was 8.3% (including 2 symptomatic chronic ulcers, 2 rectal strictures and 1 post-procedure fever). One patient with rectal stricture was successfully treated with mechanical rectal dilation. All APC sessions were well
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