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S1602: Characteristics of Laterally Spreading Tumours (LST) of the Colorectum and Therapeutic Strategy
Abstracts not widely used due to the limited study about its safety during the procedure. So, we evaluated the cardiopulmonary effect of unsedated N-EGD during the procedure, compared with that of sedated transoral EGD (O-EGD) in this study.Patients/Methods: A total of 200 patients referred for diagnostic endoscopy were randomized prospectively to have unsedated N-EGD (n ⫽ 100) or sedated O-EGD (n ⫽ 100). We compared between two groups about cardiopulmonary parameters, such as blood pressure(BP), heart rate(HR) and arterial oxygen saturation at the time of pre-procedure, 2 and 4 minutes after intubation, and post-procedure, and hemodynamic variation (difference between max. and min. of cardiopulmonary parameters) and procedure time, such as insertion time (from the mouth/nostril to the duodenum) and total procedure time.Result: There were no significant differences in the demographic features between two groups. Insertion time and total procedure time of the unsedated N-EGD group were significantly longer than the sedated O-EGD group (p⬍0.05). Hemodynamic variations of systolic and diastolic BP, HR, and O2 saturation of the unsedated N-EGD group were significantly lower than that of the sedated O-EGD group during the procedure (p⬍0.05).Conclusion: The unsedated N-EGD showed a significantly more stable cardiopulmonary condition than the sedated O-EGD during the procedure. Therefore, unsedated N-EGD might be recommended for cardiopulmonary compromised patients.
NG lesions more than 20mm in diameter were associated with high rate (23.7%) of submucosal invasion. Pathologically the muscularis mucosae was more highly destroyed in LST-NG than in LST-G (3.2% vs 1.8%). Residual adenomatous component was recognized in 57.6% of granular-type LSTs but only in 14.6% of nongranular-type. When considering the most suitable therapeutic strategy for LSTs, LST-G can be treated with endoscopic piecemeal resection technique (EPMR) due to its low rate of submucosal invasion. In contrast, LST-NG type should be removed en bloc because of higher potential for invasion and more difficulty in diagnosing depth and extent of invasion. Even pit pattern analysis with magnifying colonscopy was not so perfect in the prediction of histology of LST-NG.[CONCLUSIONS] Clinicopathological characteristics of LST are different among subgroups; therefore you should be careful when determining the treatment method.
S1601 Direct Peroral Cholangioscopy With an Ultraslim Endoscope and Intraductal Balloon Without the Use of a Previously Placed Guidewire to Maintain Access: A Feasibility Study Tae Yoon Lee, Dong Choon Seol, Jeong Hwan Kim, Won Hyeok Choe, In Kyung Sung, Hyung-Seok Park, Sung Noh Hong, Eun Kwang Choi, Chan Sup Shim
BACKGROUND: In vivo optical diagnosis of small colorectal polyps has potential clinical and cost advantages. Narrow band imaging (NBI) and autofluorescence (AFI) are new optical endoscopic modalities that are available at a push of a button and would be attractive modalities for optical diagnosis. In order for optical diagnosis to become routine clinical practice, a good inter-observer agreement between endoscopists is required. The aim of this study was to assess inter-observer variability and diagnostic accuracy compared to white light endoscopy when using commercially available “push-button” endoscopic imaging modalities to characterise small colonic polyps. METHODS: High quality still images taken using white light (WLE), AFI and NBI, with and without magnification (NBI, NBImag) of eighty polyps ⬍ 10mm in size (40 adenomas, 40 hyperplastic), prospectively collected at St Mark’s hospital as a part of an earlier study, were assessed by nine experienced colonoscopists (4 experts and 5 non-experts) from five UK centres, between May and October 2008. Histology was the gold standard. Inter-observer agreement was calculated and expressed using kappa statistic. Fisher’s exact test was used to compare sensitivity, specificity, and accuracy between advanced imaging techniques and WLE, with p-value Bonferroni adjusted. RESULTS: Mean polyp size was 4.5mm (standard deviation, SD 3.1). Inter-observer agreement was moderate, Table 1. Interobserver agreement with NBImag was better, but only in the expert group.Sensitivity was significantly higher when using NBImag compared to WLE, for both experts (149/160, 0.93 vs. 109/160, 0.68; p⬍0.001) and non-experts (179/200, 0.90 vs. 104/ 200, 0.52, p⬍0.001). Similarly, accuracy was higher when using NBImag compared to WLE for both experts (244/320, 0.76 vs. 204/320, 0.64; p⫽0.003) and non-experts (244/400, 0.61 vs. 161/400, 0.40; p⬍0.001). CONCLUSIONS: As NBImag had the best inter-observer agreement in the expert group and improved sensitivity and accuracy for both expert and non-experts, compared to WLE, it appears to be the optimal advanced imaging modality for optical diagnosis at present. Prospective real time clinical evaluation is required to determine the relative diagnostic contributions of each imaging modality when used individually or in combination.
Background: Peroral cholangioscopy (POC) offers direct visualization of the bile duct and facilitates diagnostic and therapeutic procedures. Previous studies which examined the feasibility of direct POC by using an ultra-slim upper endoscope needed a guidewire which was previously placed by endoscopic retrograde cholangiopancreatography (ERCP) within the intrahepatic duct to maintain access.Objective: To evaluate the feasibility and usefulness of direct POC using an ultraslim endoscope and intraductal balloon without the use of a previously placed guidewire within the intrahepatic duct (IHD) to maintain access.Main Outcome Measurements: Success rate of this technique, diagnostic or therapeutic feasibility.Patients and Methods: Thirteen patients with common bile duct (CBD) stone underwent direct POC without the use of immediately prior ERCP to place a guidewire to maintain access. All patients had previously undergone combined endoscopic sphincterotomy, papillary balloon dilatation (12-15mm), and stone extraction. After the ultraslim endoscope reached the Ampulla of the Vater, the 5F balloon catheter with a guidewire was advanced into a branch of IHD and used to maintain access while an ultraslim endoscope was advanced over the balloon catheter into the CBD and onward.Results: Intraductal balloon-guided direct POC without the use of a previously placed guidewire was performed successfully in 10 of 13 patients (77%). Four remnant CBD stones were detected among 10 patients with CBD stone. In 2 patients with small residual CBD stones, CBD were irrigated with normal saline solution via direct POC channel and CBD stones were removed successfully. In 2 patients with large residual stones, subsequent ERCP was performed. No procedurerelated complication occurred.Conclusions: Intraductal balloon guided direct POC without the use of a previously placed guidewire was feasible and appears to be a convenient and useful endoscopic procedure for direct visualization of the biliary system, especially after sufficient papillary dilatation.
S1603 Characterisation of Small Colonic Polyps: Inter-Observer Agreement With Advanced Imaging Techniques in Expert and Non-Expert Groups Ana Ignjatovic, James E. East, Thomas Guenther, Hoare Jonathan, John Morris, Krish Ragunath, Anthony Shonde, Jon Simmons, Noriko Suzuki, Siwan Thomas-Gibson, Brian P. Saunders
Table 1 Inter-observer agreement All observers Experts Non-experts
WLE () (95% CI)
AFI () (95% CI)
NBI () (95% CI)
NBImag () (95% CI)
0.41 (0.36, 0.46) 0.48 (0.41, 0.55) 0.49 (0.44, 0.54) 0.44 (0.40, 0.48) 0.41 (0.30, 0.52) 0.48 (0.34, 0.61) 0.48 (0.37, 0.59) 0.63 (0.53, 0.72) 0.43 (0.31, 0.55) 0.52 (0.34, 0.71) 0.48 (0.37, 0.59) 0.30 (0.22, 0.37)
S1602 Characteristics of Laterally Spreading Tumours (LST) of the Colorectum and Therapeutic Strategy Tomoyuki Ishigaki, Hiromasa Oikawa, Noriyuki Ogata, Hiroki Nakamura, Shingo Matsudaira, Kouki Kudo, Yusuke Yagawa, Takemasa Hayashi, Hideyuki Miyachi, Nobunao Ikehara, Fuyuhiko Yamamura, Kazuo Ohtsuka, Hiroshi Kashida, Shin-Ei Kudo
S1604 Can Optical Biopsy Replace Pathology? In Vivo Endocytoscopic Evaluation of Gastric Cancer Hitomi Minami, Haruhiro Inoue, Akira Yokoyama, Hironari Shiwaku, Shigeharu Hamatani, Shin-Ei Kudo
[BACKGROUND] Laterally spreading tumours (LSTs) of the colorectum are defined as circumferentially extending neoplasms large (ⱖ10mm) in diameter. They are usually good indication for endoscopic mucosal resection (EMR) technique because they are rather benign in spite of their large diameter. [AIM] To clarify the nature of LSTs and to determine criteria for endoscopic treatment of them.[METHODS] A total of 29291 early colorectal cancers and adenomas were resected endoscopically or surgically between April 1985 and Jun 2009. They were devided into granular-type (LST-G) and nongranular-type (LST-NG) and evaluated for the magnifying endoscopic findings and association with submucosal invasion.[RESULTS] Out of 29291 lesions,there were 907 submucosally invasive (T1) cancers. The total number of LSTs was 1713 (5.8%) and submucosally invasive LSTs accounted for 173 lesions (19.1% of T1 cancer and 10.0% of LSTs). The rate of submucosal invasion was significantly higher in LST-NG than in LST-G (12.7% vs 7.3%; p⬍0.01). Presence of a large nodule in LST-G was associated with higher submucosal invasion. Large LST-
Background and aim :Distribution of various kinds of Image enhance technique and magnifying endoscopy gets us closer to new era of endoscopic diagnosis. In addition, development of ultra-high magnifying endoscopy enables in vivo pathological diagnosis. Our newly developed single CCD Endocytoscopy enables in vivo observation of cellular atypia during routine endoscopic examination. The purpose of this study is to clarify the efficacy of endocytoscopy and Endocytoscopic Atypia (ECA) classification in the stomach.Patients and method: Consecutive 115 patients who underwent endocytoscopy in our institution from July 2006 to Oct. 2009 were included in this study. Using endocytoscopy, 199 gastric lesions were classified according to ECA classification. A newly designed incorporated endocytoscopy (Olympus) can achieve entire series of endoscopic examination including macroscopic observation, usual magnifying endoscopy, and ultra-high magnification. In ECA classification endocytoscopic images were categorized into five groups according to size and uniformity of nuclei, number
www.giejournal.org
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB205
NG lesions more than 20mm in diameter were associated with high rate (23.7%) of submucosal invasion. Pathologically the muscularis mucosae was more highly destroyed in LST-NG than in LST-G (3.2% vs 1.8%). Residual adenomatous component was recognized in 57.6% of granular-type LSTs but only in 14.6% of nongranular-type. When considering the most suitable therapeutic strategy for LSTs, LST-G can be treated with endoscopic piecemeal resection technique (EPMR) due to its low rate of submucosal invasion. In contrast, LST-NG type should be removed en bloc because of higher potential for invasion and more difficulty in diagnosing depth and extent of invasion. Even pit pattern analysis with magnifying colonscopy was not so perfect in the prediction of histology of LST-NG.[CONCLUSIONS] Clinicopathological characteristics of LST are different among subgroups; therefore you should be careful when determining the treatment method.
S1601 Direct Peroral Cholangioscopy With an Ultraslim Endoscope and Intraductal Balloon Without the Use of a Previously Placed Guidewire to Maintain Access: A Feasibility Study Tae Yoon Lee, Dong Choon Seol, Jeong Hwan Kim, Won Hyeok Choe, In Kyung Sung, Hyung-Seok Park, Sung Noh Hong, Eun Kwang Choi, Chan Sup Shim
BACKGROUND: In vivo optical diagnosis of small colorectal polyps has potential clinical and cost advantages. Narrow band imaging (NBI) and autofluorescence (AFI) are new optical endoscopic modalities that are available at a push of a button and would be attractive modalities for optical diagnosis. In order for optical diagnosis to become routine clinical practice, a good inter-observer agreement between endoscopists is required. The aim of this study was to assess inter-observer variability and diagnostic accuracy compared to white light endoscopy when using commercially available “push-button” endoscopic imaging modalities to characterise small colonic polyps. METHODS: High quality still images taken using white light (WLE), AFI and NBI, with and without magnification (NBI, NBImag) of eighty polyps ⬍ 10mm in size (40 adenomas, 40 hyperplastic), prospectively collected at St Mark’s hospital as a part of an earlier study, were assessed by nine experienced colonoscopists (4 experts and 5 non-experts) from five UK centres, between May and October 2008. Histology was the gold standard. Inter-observer agreement was calculated and expressed using kappa statistic. Fisher’s exact test was used to compare sensitivity, specificity, and accuracy between advanced imaging techniques and WLE, with p-value Bonferroni adjusted. RESULTS: Mean polyp size was 4.5mm (standard deviation, SD 3.1). Inter-observer agreement was moderate, Table 1. Interobserver agreement with NBImag was better, but only in the expert group.Sensitivity was significantly higher when using NBImag compared to WLE, for both experts (149/160, 0.93 vs. 109/160, 0.68; p⬍0.001) and non-experts (179/200, 0.90 vs. 104/ 200, 0.52, p⬍0.001). Similarly, accuracy was higher when using NBImag compared to WLE for both experts (244/320, 0.76 vs. 204/320, 0.64; p⫽0.003) and non-experts (244/400, 0.61 vs. 161/400, 0.40; p⬍0.001). CONCLUSIONS: As NBImag had the best inter-observer agreement in the expert group and improved sensitivity and accuracy for both expert and non-experts, compared to WLE, it appears to be the optimal advanced imaging modality for optical diagnosis at present. Prospective real time clinical evaluation is required to determine the relative diagnostic contributions of each imaging modality when used individually or in combination.
Background: Peroral cholangioscopy (POC) offers direct visualization of the bile duct and facilitates diagnostic and therapeutic procedures. Previous studies which examined the feasibility of direct POC by using an ultra-slim upper endoscope needed a guidewire which was previously placed by endoscopic retrograde cholangiopancreatography (ERCP) within the intrahepatic duct to maintain access.Objective: To evaluate the feasibility and usefulness of direct POC using an ultraslim endoscope and intraductal balloon without the use of a previously placed guidewire within the intrahepatic duct (IHD) to maintain access.Main Outcome Measurements: Success rate of this technique, diagnostic or therapeutic feasibility.Patients and Methods: Thirteen patients with common bile duct (CBD) stone underwent direct POC without the use of immediately prior ERCP to place a guidewire to maintain access. All patients had previously undergone combined endoscopic sphincterotomy, papillary balloon dilatation (12-15mm), and stone extraction. After the ultraslim endoscope reached the Ampulla of the Vater, the 5F balloon catheter with a guidewire was advanced into a branch of IHD and used to maintain access while an ultraslim endoscope was advanced over the balloon catheter into the CBD and onward.Results: Intraductal balloon-guided direct POC without the use of a previously placed guidewire was performed successfully in 10 of 13 patients (77%). Four remnant CBD stones were detected among 10 patients with CBD stone. In 2 patients with small residual CBD stones, CBD were irrigated with normal saline solution via direct POC channel and CBD stones were removed successfully. In 2 patients with large residual stones, subsequent ERCP was performed. No procedurerelated complication occurred.Conclusions: Intraductal balloon guided direct POC without the use of a previously placed guidewire was feasible and appears to be a convenient and useful endoscopic procedure for direct visualization of the biliary system, especially after sufficient papillary dilatation.
S1603 Characterisation of Small Colonic Polyps: Inter-Observer Agreement With Advanced Imaging Techniques in Expert and Non-Expert Groups Ana Ignjatovic, James E. East, Thomas Guenther, Hoare Jonathan, John Morris, Krish Ragunath, Anthony Shonde, Jon Simmons, Noriko Suzuki, Siwan Thomas-Gibson, Brian P. Saunders
Table 1 Inter-observer agreement All observers Experts Non-experts
WLE () (95% CI)
AFI () (95% CI)
NBI () (95% CI)
NBImag () (95% CI)
0.41 (0.36, 0.46) 0.48 (0.41, 0.55) 0.49 (0.44, 0.54) 0.44 (0.40, 0.48) 0.41 (0.30, 0.52) 0.48 (0.34, 0.61) 0.48 (0.37, 0.59) 0.63 (0.53, 0.72) 0.43 (0.31, 0.55) 0.52 (0.34, 0.71) 0.48 (0.37, 0.59) 0.30 (0.22, 0.37)
S1602 Characteristics of Laterally Spreading Tumours (LST) of the Colorectum and Therapeutic Strategy Tomoyuki Ishigaki, Hiromasa Oikawa, Noriyuki Ogata, Hiroki Nakamura, Shingo Matsudaira, Kouki Kudo, Yusuke Yagawa, Takemasa Hayashi, Hideyuki Miyachi, Nobunao Ikehara, Fuyuhiko Yamamura, Kazuo Ohtsuka, Hiroshi Kashida, Shin-Ei Kudo
S1604 Can Optical Biopsy Replace Pathology? In Vivo Endocytoscopic Evaluation of Gastric Cancer Hitomi Minami, Haruhiro Inoue, Akira Yokoyama, Hironari Shiwaku, Shigeharu Hamatani, Shin-Ei Kudo
[BACKGROUND] Laterally spreading tumours (LSTs) of the colorectum are defined as circumferentially extending neoplasms large (ⱖ10mm) in diameter. They are usually good indication for endoscopic mucosal resection (EMR) technique because they are rather benign in spite of their large diameter. [AIM] To clarify the nature of LSTs and to determine criteria for endoscopic treatment of them.[METHODS] A total of 29291 early colorectal cancers and adenomas were resected endoscopically or surgically between April 1985 and Jun 2009. They were devided into granular-type (LST-G) and nongranular-type (LST-NG) and evaluated for the magnifying endoscopic findings and association with submucosal invasion.[RESULTS] Out of 29291 lesions,there were 907 submucosally invasive (T1) cancers. The total number of LSTs was 1713 (5.8%) and submucosally invasive LSTs accounted for 173 lesions (19.1% of T1 cancer and 10.0% of LSTs). The rate of submucosal invasion was significantly higher in LST-NG than in LST-G (12.7% vs 7.3%; p⬍0.01). Presence of a large nodule in LST-G was associated with higher submucosal invasion. Large LST-
Background and aim :Distribution of various kinds of Image enhance technique and magnifying endoscopy gets us closer to new era of endoscopic diagnosis. In addition, development of ultra-high magnifying endoscopy enables in vivo pathological diagnosis. Our newly developed single CCD Endocytoscopy enables in vivo observation of cellular atypia during routine endoscopic examination. The purpose of this study is to clarify the efficacy of endocytoscopy and Endocytoscopic Atypia (ECA) classification in the stomach.Patients and method: Consecutive 115 patients who underwent endocytoscopy in our institution from July 2006 to Oct. 2009 were included in this study. Using endocytoscopy, 199 gastric lesions were classified according to ECA classification. A newly designed incorporated endocytoscopy (Olympus) can achieve entire series of endoscopic examination including macroscopic observation, usual magnifying endoscopy, and ultra-high magnification. In ECA classification endocytoscopic images were categorized into five groups according to size and uniformity of nuclei, number
www.giejournal.org
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB205