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Sa1542 Large (<4cm) and Giant (≥4cm) Colorectal Polyps: a Cut-Off Polyp Size for Piecemeal Endoscopic Resection
Abstracts
(ESD). The scar was examined with magnification chromoendoscopy post resection to check for residual disease. All patients underwent follow up magnification colonoscopy at 3 and 12 months by the same endoscopist. Results: 84 endoscopic resections of lesions greater than or equal to 8 cm were undertaken, with a mean age of 72 years (SD 10.6). The location of lesions included rectum (nZ23); recto-sigmoid (nZ25); sigmoid (nZ26); descending colon (nZ2); ascending colon (nZ4) and caecum (nZ4). The mean size of the polyps was 102 mm. Histology revealed 78 tubulo-villous adenoma, 5 tubular adenomas and 1 adenocarcinomas . All lesions were resected completely with curative intent. There were 3 perforations (3.6%) all of which were closed endoscopically using clips without need for further surgery. One of the patients had evidence of post procedure haemorrhage. The local recurrence rate was 9.5%. The rate of complications and recurrence were significantly higher than that seen in patients with lesions less than 8 cm (nZ180) - (see table 1). Conclusions: Endoscopic resection of giant colorectal adenomas may be undertaken with low risk of complications thereby avoiding the need for surgical resection. Nonetheless, it is associated with a higher risk of complications, recurrence and admission to hospital when compared with lesions less than 8 cm and therfore should be considered in specialist units.
Outcome data for endoscopic resection of colorectal lesions Less than 8 cm lesions (n[180) Giant adenomas (n[84) % % Admission to hospital Recurrence Perforation
3.3
15.4
2.8 1.7
9.5 6.0
Sa1540 Long-Term Outcomes and Prognostic Factors for Local Recurrence After Argon Plasma Coagulation Ablation for Gastric Adenoma With Low Grade Dysplasia on an Outpatient Basis Jin Hong Kim*, Sun Gyo Lim, Sung Jae Shin, Kee Myung Lee, Byung Moo Yoo Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea (the Republic of) Background: Argon plasma coagulation (APC) ablation has been attempted as a considerable treatment option for many gastrointestinal tract diseases. For the treatment of gastric adenoma (GA) with low grade dysplasia (LGD), APC ablation seems to be easier and safer than other endoscopic treatment modalities such as EMR or ESD. The purpose of this study was to evaluate the adverse event, long-term outcomes and prognostic factors for local recurrence after APC ablation for GA with LGD on an outpatient basis. Material and method: Patients with GA with LGD were treated with APC ablation (60w) after submucosal saline injection on an outpatient basis at Ajou University Hospital from January 2004 to June 2014. We scheduled follow-up endoscopy with forceps biopsy at 3, 6, 12 months, thereafter every 12 months. Adverse events and local recurrence were evaluated. Results: 97 lesions of GA with LGD from 91 patients (mean age 60.95 10.3 years, range 34-81) were treated with APC ablation. The endoscopic pattern of the lesions included flat elevated type in 83 and depressed type in 14. The location of the lesions included 3 in the upper part of the stomach, 35 in the middle part and 59 in the lower part. After APC ablation procedure, 7 patients re-visited to the hospital due to abdominal pain (2), bleeding (4) and pneumoperitoneum without evidence of perforation (1), Only 2 bleeding patients needed re-intervention (APC) , others were discharged after conservative care. During 39 months of the median follow-up period (3w134 months), local recurrence of GA with LGD were noted in 4.1% (4/97). Depressed lesion was identified as a unique predictive factor of local recurrence on multivariate analysis (p valueZ0.018), although longest diameter, shortest diameter and surface area were also identified as its predictive factors on univariate analysis. Conclusion: APC ablation for treatment of GA with LGD is an effective treatment option with a low local recurrence rate, low rates of adverse events and short hospital stay duration. We may expect depressed lesion as an affecting factor for local recurrence after APC ablation.
Sa1541 a Second-Look Endoscopy After Endoscopic Submucosal Dissection for Left-Sided Colorectal Epithelial Neoplasm May Be Unnecessary: Retrospective Analysis of Postendoscopic Submucosal Dissection Bleeding Soo-Kyung Park*, Bong Min Ko, Yu Sik Myung, Jae Pil Han, Seong Ran Jeon, Jin-Oh Kim, Moon Sung Lee Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon and Seoul, Korea (the Republic of) Background and Aims: Endoscopic submucosal dissection (ESD) is one of the curative endoluminal surgical procedures for colorectal epithelial neoplasms. Although second-look endoscopy (SLE) is frequently performed after gastric ESD, no reports have assessed the role of SLE in colorectal ESD. We investigated whether a SLE after
AB254 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
ESD is effective in the prevention of delayed bleeding and evaluate factors associated with post ESD ulcer finding at SLE. Methods: This study included 168 consecutive patients in whom 169 left-sided colorectal epithelial neoplasms were resected using ESD between March 2005 and December 2013 in a tertiary referral hospital. After removal of the lesion, prophylactic coagulation for all visible major vessels (O2mm) (coagulation group) or prophylactic clip closure (clip group) for post ESD ulcer was performed. According to remnant minor vessels, type of post ESD ulcer was classified into visible vessel group and no visible vessel group. The post-ESD ulcers were categorized according to the Forrest classification: high-risk ulcer stigma (type I and IIa) and low-risk ulcer stigma (type IIb, IIc and III). Results: SLE was performed in 97 (55.7%) lesions on the day following ESD. There was no delayed bleeding both in the SLE group and no-SLE group. SLE revealed that the incidence of type IIb, IIc and III ulcer stigma was 12 (12.4%), 26 (26.8%) and 59 (60.8%) respectively and there was no high risk ulcer stigma. On SLE, one patient with IIb ulcer stigma performed clipping due to mild oozing bleeding and one patient with IIc ulcer stigma performed argon plasma coagulation as oozing bleeding from a margin of ulcer was occurred after air inflation. SLE finding showed no association with methods of prophylactic hemostasis (type II, coagulation group 35.8% vs. clip group 43.2%, pZ0.59) and type of post ESD ulcer (type II, visible vessel group 38.2% vs. no visible vessel group 68.2%, pZ0.49). Conclusions: A SLE after left-sided colorectal ESD may contribute little to the prevention of delayed bleeding if prophylactic hemostasis on major vessel of post ESD ulcer is performed.
Sa1542 Large (!4cm) and Giant (R4cm) Colorectal Polyps: a Cut-Off Polyp Size for Piecemeal Endoscopic Resection Zacharias P. Tsiamoulos*, Timothy R. Elliott, Noriko Suzuki, Simon Peake, Leonidas A. Bourikas, Paul Bassett, Brian P. Saunders Wolfson Unit for Endoscopy, St Mark, London, United Kingdom Introduction: Piecemeal Endoscopic Mucosal Resection(p-EMR)is a standard and safe endoscopic technique for resection of large colorectal polyps (O2cm). Limited data are available regarding p-EMRof giant polyps (O4cm). Methods: A prospective study recording short and long term outcomes after p-EMR for colorectal polyps O 2cmbetween Jan 2010 and August 2012 was conducted. We compared two cohorts of patients: group A with large polyps (2 to!4cm) vsgroup B with giant (R4cm) polyps. Chi-square/Fischer’s analysis was performed between categorical variables including patient demographics/polyp features/techniquesapplied {p-EMR, p-EMR with spiral snare, hybrid p-EMR/endoscopic mucosal ablation (EMA) and endoscopic submucosal dissection (ESD)}). Our primary outcome was to compare the safety, efficacy and complication rate between the two groups. Results: Group/B patients were older than group/A patients (mean 70.6vs67.8 yrs/ pZ0.01) and were more likely to have come from a tertiary referral source (p Z 0.05). Large polyp referrals were almost twice as frequent as giant polyp referrals (218vs123/p!0.001). Median polyp size was 2.5cm ingroup A and 5cm in group B. Giant polyps were most commonly found in the recto-sigmoid segment (26% rectum &28% sigmoid/p!0.001), whilst large polyps were more evenly distributed throughout the colon. Paris 0+Is+IIa (20%vs5%/p!0.001) and G-mixed type LST (19%vs5%/p!0.001) were more frequent in group/B, indicating that giant lesions were less likely to be flat. NICE type II vascular pattern was recorded equally in both groups. No significant difference in cancer prevalencewas recorded between the groups. Endoscopic excision was complete in 89% in large (median time 18min) and in 70% in giant groups (median time 38min). All large polyps were excised in one session, whilst 4% of giant polyps required more than one session. Incomplete submucosal lift (46%vs63%/pZ0.002) and difficult polyp position (45%vs63%/p! 0.001) were more common in giant polyps. Spiral-snare EMR (6%vs28%/p!0.001) and hybrid ESD (0%vs7%/p!0.001) techniques were more commonly used in giant than in large polyps. Procedural bleeding occurred more frequently in giant polyps (5%vs17%/p!0.001). Delayed bleeding was also significantly higher in giant polyps (15%vs34%/p!0.001), but hospitalisation or further intervention did not vary significantly vary by polyp size. The overall long-term recurrence at 24 months was 17% (11%vs28%/pZ0.02). The follow up occurrence was more frequent for giant polyps at 3-month (43%vs72%/p!0.001) and 9-month (14%vs26%/pZ0.007) intervals. Conclusion: Piecemeal resection is a safe and efficacious modality for the resection of colorectal polyps O4cm. However, these giant polyps more often require spiral snare or hybrid resection techniques and their higher adenoma recurrence rate post p-EMR may dictate shorter surveillance intervals.
Sa1543 Long Term Follow-Up Result of Endoscopic Resection of Gastric Gastrointestinal Stromal Tumor Min Jae Yang*, Sun Gyo Lim, Sung Jae Shin, Kee Myung Lee Ajou University School of Medicine, Suwon, Korea (the Republic of) Background: Although endoscopic resection (ER) for various gastric tumors has been widely promoted, the suitability for gastrointestinal stromal tumor (GIST) is not clear. The aim of this study was to evaluate the feasibility, efficacy, safety, and long-term follow-up results of ER for gastric GIST. Method: The medical records of 49 patients who underwent ER for gastric GIST were collected between January 2000 and July 2014. After procedure, the recurrence of tumor was checked by endoscopy and abdominal CT during follow-up. Demographics, clinical data, therapeutic outcomes, complications, pathological characteristics, and follow-up outcomes were
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(ESD). The scar was examined with magnification chromoendoscopy post resection to check for residual disease. All patients underwent follow up magnification colonoscopy at 3 and 12 months by the same endoscopist. Results: 84 endoscopic resections of lesions greater than or equal to 8 cm were undertaken, with a mean age of 72 years (SD 10.6). The location of lesions included rectum (nZ23); recto-sigmoid (nZ25); sigmoid (nZ26); descending colon (nZ2); ascending colon (nZ4) and caecum (nZ4). The mean size of the polyps was 102 mm. Histology revealed 78 tubulo-villous adenoma, 5 tubular adenomas and 1 adenocarcinomas . All lesions were resected completely with curative intent. There were 3 perforations (3.6%) all of which were closed endoscopically using clips without need for further surgery. One of the patients had evidence of post procedure haemorrhage. The local recurrence rate was 9.5%. The rate of complications and recurrence were significantly higher than that seen in patients with lesions less than 8 cm (nZ180) - (see table 1). Conclusions: Endoscopic resection of giant colorectal adenomas may be undertaken with low risk of complications thereby avoiding the need for surgical resection. Nonetheless, it is associated with a higher risk of complications, recurrence and admission to hospital when compared with lesions less than 8 cm and therfore should be considered in specialist units.
Outcome data for endoscopic resection of colorectal lesions Less than 8 cm lesions (n[180) Giant adenomas (n[84) % % Admission to hospital Recurrence Perforation
3.3
15.4
2.8 1.7
9.5 6.0
Sa1540 Long-Term Outcomes and Prognostic Factors for Local Recurrence After Argon Plasma Coagulation Ablation for Gastric Adenoma With Low Grade Dysplasia on an Outpatient Basis Jin Hong Kim*, Sun Gyo Lim, Sung Jae Shin, Kee Myung Lee, Byung Moo Yoo Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea (the Republic of) Background: Argon plasma coagulation (APC) ablation has been attempted as a considerable treatment option for many gastrointestinal tract diseases. For the treatment of gastric adenoma (GA) with low grade dysplasia (LGD), APC ablation seems to be easier and safer than other endoscopic treatment modalities such as EMR or ESD. The purpose of this study was to evaluate the adverse event, long-term outcomes and prognostic factors for local recurrence after APC ablation for GA with LGD on an outpatient basis. Material and method: Patients with GA with LGD were treated with APC ablation (60w) after submucosal saline injection on an outpatient basis at Ajou University Hospital from January 2004 to June 2014. We scheduled follow-up endoscopy with forceps biopsy at 3, 6, 12 months, thereafter every 12 months. Adverse events and local recurrence were evaluated. Results: 97 lesions of GA with LGD from 91 patients (mean age 60.95 10.3 years, range 34-81) were treated with APC ablation. The endoscopic pattern of the lesions included flat elevated type in 83 and depressed type in 14. The location of the lesions included 3 in the upper part of the stomach, 35 in the middle part and 59 in the lower part. After APC ablation procedure, 7 patients re-visited to the hospital due to abdominal pain (2), bleeding (4) and pneumoperitoneum without evidence of perforation (1), Only 2 bleeding patients needed re-intervention (APC) , others were discharged after conservative care. During 39 months of the median follow-up period (3w134 months), local recurrence of GA with LGD were noted in 4.1% (4/97). Depressed lesion was identified as a unique predictive factor of local recurrence on multivariate analysis (p valueZ0.018), although longest diameter, shortest diameter and surface area were also identified as its predictive factors on univariate analysis. Conclusion: APC ablation for treatment of GA with LGD is an effective treatment option with a low local recurrence rate, low rates of adverse events and short hospital stay duration. We may expect depressed lesion as an affecting factor for local recurrence after APC ablation.
Sa1541 a Second-Look Endoscopy After Endoscopic Submucosal Dissection for Left-Sided Colorectal Epithelial Neoplasm May Be Unnecessary: Retrospective Analysis of Postendoscopic Submucosal Dissection Bleeding Soo-Kyung Park*, Bong Min Ko, Yu Sik Myung, Jae Pil Han, Seong Ran Jeon, Jin-Oh Kim, Moon Sung Lee Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon and Seoul, Korea (the Republic of) Background and Aims: Endoscopic submucosal dissection (ESD) is one of the curative endoluminal surgical procedures for colorectal epithelial neoplasms. Although second-look endoscopy (SLE) is frequently performed after gastric ESD, no reports have assessed the role of SLE in colorectal ESD. We investigated whether a SLE after
AB254 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
ESD is effective in the prevention of delayed bleeding and evaluate factors associated with post ESD ulcer finding at SLE. Methods: This study included 168 consecutive patients in whom 169 left-sided colorectal epithelial neoplasms were resected using ESD between March 2005 and December 2013 in a tertiary referral hospital. After removal of the lesion, prophylactic coagulation for all visible major vessels (O2mm) (coagulation group) or prophylactic clip closure (clip group) for post ESD ulcer was performed. According to remnant minor vessels, type of post ESD ulcer was classified into visible vessel group and no visible vessel group. The post-ESD ulcers were categorized according to the Forrest classification: high-risk ulcer stigma (type I and IIa) and low-risk ulcer stigma (type IIb, IIc and III). Results: SLE was performed in 97 (55.7%) lesions on the day following ESD. There was no delayed bleeding both in the SLE group and no-SLE group. SLE revealed that the incidence of type IIb, IIc and III ulcer stigma was 12 (12.4%), 26 (26.8%) and 59 (60.8%) respectively and there was no high risk ulcer stigma. On SLE, one patient with IIb ulcer stigma performed clipping due to mild oozing bleeding and one patient with IIc ulcer stigma performed argon plasma coagulation as oozing bleeding from a margin of ulcer was occurred after air inflation. SLE finding showed no association with methods of prophylactic hemostasis (type II, coagulation group 35.8% vs. clip group 43.2%, pZ0.59) and type of post ESD ulcer (type II, visible vessel group 38.2% vs. no visible vessel group 68.2%, pZ0.49). Conclusions: A SLE after left-sided colorectal ESD may contribute little to the prevention of delayed bleeding if prophylactic hemostasis on major vessel of post ESD ulcer is performed.
Sa1542 Large (!4cm) and Giant (R4cm) Colorectal Polyps: a Cut-Off Polyp Size for Piecemeal Endoscopic Resection Zacharias P. Tsiamoulos*, Timothy R. Elliott, Noriko Suzuki, Simon Peake, Leonidas A. Bourikas, Paul Bassett, Brian P. Saunders Wolfson Unit for Endoscopy, St Mark, London, United Kingdom Introduction: Piecemeal Endoscopic Mucosal Resection(p-EMR)is a standard and safe endoscopic technique for resection of large colorectal polyps (O2cm). Limited data are available regarding p-EMRof giant polyps (O4cm). Methods: A prospective study recording short and long term outcomes after p-EMR for colorectal polyps O 2cmbetween Jan 2010 and August 2012 was conducted. We compared two cohorts of patients: group A with large polyps (2 to!4cm) vsgroup B with giant (R4cm) polyps. Chi-square/Fischer’s analysis was performed between categorical variables including patient demographics/polyp features/techniquesapplied {p-EMR, p-EMR with spiral snare, hybrid p-EMR/endoscopic mucosal ablation (EMA) and endoscopic submucosal dissection (ESD)}). Our primary outcome was to compare the safety, efficacy and complication rate between the two groups. Results: Group/B patients were older than group/A patients (mean 70.6vs67.8 yrs/ pZ0.01) and were more likely to have come from a tertiary referral source (p Z 0.05). Large polyp referrals were almost twice as frequent as giant polyp referrals (218vs123/p!0.001). Median polyp size was 2.5cm ingroup A and 5cm in group B. Giant polyps were most commonly found in the recto-sigmoid segment (26% rectum &28% sigmoid/p!0.001), whilst large polyps were more evenly distributed throughout the colon. Paris 0+Is+IIa (20%vs5%/p!0.001) and G-mixed type LST (19%vs5%/p!0.001) were more frequent in group/B, indicating that giant lesions were less likely to be flat. NICE type II vascular pattern was recorded equally in both groups. No significant difference in cancer prevalencewas recorded between the groups. Endoscopic excision was complete in 89% in large (median time 18min) and in 70% in giant groups (median time 38min). All large polyps were excised in one session, whilst 4% of giant polyps required more than one session. Incomplete submucosal lift (46%vs63%/pZ0.002) and difficult polyp position (45%vs63%/p! 0.001) were more common in giant polyps. Spiral-snare EMR (6%vs28%/p!0.001) and hybrid ESD (0%vs7%/p!0.001) techniques were more commonly used in giant than in large polyps. Procedural bleeding occurred more frequently in giant polyps (5%vs17%/p!0.001). Delayed bleeding was also significantly higher in giant polyps (15%vs34%/p!0.001), but hospitalisation or further intervention did not vary significantly vary by polyp size. The overall long-term recurrence at 24 months was 17% (11%vs28%/pZ0.02). The follow up occurrence was more frequent for giant polyps at 3-month (43%vs72%/p!0.001) and 9-month (14%vs26%/pZ0.007) intervals. Conclusion: Piecemeal resection is a safe and efficacious modality for the resection of colorectal polyps O4cm. However, these giant polyps more often require spiral snare or hybrid resection techniques and their higher adenoma recurrence rate post p-EMR may dictate shorter surveillance intervals.
Sa1543 Long Term Follow-Up Result of Endoscopic Resection of Gastric Gastrointestinal Stromal Tumor Min Jae Yang*, Sun Gyo Lim, Sung Jae Shin, Kee Myung Lee Ajou University School of Medicine, Suwon, Korea (the Republic of) Background: Although endoscopic resection (ER) for various gastric tumors has been widely promoted, the suitability for gastrointestinal stromal tumor (GIST) is not clear. The aim of this study was to evaluate the feasibility, efficacy, safety, and long-term follow-up results of ER for gastric GIST. Method: The medical records of 49 patients who underwent ER for gastric GIST were collected between January 2000 and July 2014. After procedure, the recurrence of tumor was checked by endoscopy and abdominal CT during follow-up. Demographics, clinical data, therapeutic outcomes, complications, pathological characteristics, and follow-up outcomes were
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