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Tu1527 The Detection of Polyps and Advanced Lesions in HIV Infected Individuals During Colonoscopy
Abstracts
cumbersome due to entrapment in the head of the polyp and risk of slipping off immediately after polypectomy. The latter is particularly frequent there is not enough room for endoloop application due to a short polyp stalk. We report about the use of a simple and safe method combining the use of clips and endoloop. Methods: Patients with large pedunculated polyps (⬎3 cm) were included. We used a prototype therapeutic sigmoidoscope (Olympus, Tokyo, Japan), 80 cm long, equipped with two working channels (2.8 mm and 3.7 mm, respectively). One working channel has an up/down elevator. Using a “twohanded” approach, 2 clips were initially placed at the base of the stalk, on two opposite sides. In order to fix it securely, the endoloop was then placed at the base of the stalk below the two clips. To facilitate the procedure the endoloop was opened through one channel, the polyp was grabbed through the other channel by a tripod and then pulled inside the endoloop. Thus, the endoloop was subsequently firmly secured at the base of the stalk. If necessary, the same procedure was repeated to capture the polyp within the diathermic snare for resection. The procedures were performed under conscious sedation using meperidine and midazolam. Results: Twenty-five pedunculated polyps in 24 patients (13 F, 11 M; median age 59) were resected with the “clip and loop” technique. It was possible to place an endoloop successfully below the clips at the basis of the stalk and perform a resection in all cases. No major complication occurred. Particularly, in no case the endoloop fell off after resection. In comparison to the previous cases performed with the endoloop only, the success rate in terms of correct and durable endoloop placement was higher (100% vs. 84%). Conclusions: Application of endoloop below the clips is feasible and safe and prevents slipping off of the endoloop after polypectomy. Use of a combination of clips and endoloop is an effective prophylactic measure to prevent bleeding after polypectomy of large pedunculated polyps, also when the stalk is short.
Tu1526 Endoscopic Submucosal Dissection (ESD) up to 11 cm for 54 Large Laterally Spreading Tumors or Local Recurrencies in the Recto-Sigmoid Juergen Hochberger, Guenter Wilhelms, Martin Froelich, Detlev Menke, Edris Wedi, Karl-Friedrich Buerrig, Elena Kruse Gastroenterology, Intervent. Endoscopy, St. Bernward Hospital, Hildesheim, Germany Piecemeal-EMR of lateral spreading tumors (LST) in the colo-rectum over 2 cm is associated with a recurrence rate of about 15% (3-32%). Adenomata have a sizedependent progressive risk of malignant transformation especially over 2 cm. ESD provides an ’en bloc’ specimen allowing a precise vertical and lateral histopathological evaluation and promises a low recurrence rate (0-3%). However, ESD experience in the ’Western World’ is limited compared to published large Japanese series.Patients and Method: March 28, 2006 to November 11, 2010 52 patients were treated with 54 ESDs (1x 3ESDs): 71 y (4990 y); 19 f, 34 m; ASA 2-4 with a flat or elevated polyp in the recto-sigmoid over 2 cm. In 1 patient 3 lesions were resected in 2 ESD sessions. 11/52 patients (21%) had a previous local treatment (7x EMR; 4x surgical full-thickness resection). Location: 31/54 (57%) in the distal, 16 (30%) in the middle and 7(13%) in the proximal rectum or sigma. Results: 46 of 54 lesions could be resected macroscopically ’en bloc’ (85%); histologically a clear adenoma/tumor-free margin was present in 34/54 (63%). In 5 ESDs (9%) a clear statment was not possible due to termal artefacts. The macro-pathological size of the formalinfixed specimen pinned on kork ranged from 2.2 cm to 11 cm for the largest diameter (48/54 specimen ⱖ3 cm)Histopathology revealed foci of adenocarcinoma in 6/54 (11%), foci of a neuroendocrine tumor in 1 (1.85%; net), lymphoma in 1. In 46/54 specimen histology showed tubulovillous (44) or villous (2) adenomata (37% LG-IEN; 24/44⫽ 44% HG-IEN). 32/54 (59%) of all lesions showed HG-IEN or cancer/lym/net. However a referral bias seems probable.Median follow-up was 301 days (20-1,708 days). Two patients died unrelated to the resection.4 pT1 cancers underwent surgery due L⫹; V⫹/G3; R1 (2 cases). The neuroendocrine tumor due to V⫹, R1 G3. All other cases were followed conservatively by endoscopy and telephone interviews. Complications: 3 perforations due to wall damage during or following ESD (5.6 %) managed conservatively. In one case ESD was accomponied by a rare colonic methan gas explosion and the patient operated for safety reasons (prior ESD specimen R0). 5 minor bleedings (9%) occured, no patient needed blood transfusion (0%). Proven recurrence macroscopically and in local biopsies was 0%. In one case (1.85%) a secondary 6 mm lesion close to the scar was found after 12 month and resected (R0, LGD tv adenoma). Conclusions: ESD up to 11 cm for large mucosal lesions or local recurrencies after EMR/ surgical full-thickness resection in the rectosigmoid is feasable in the western endoscopic world. A rate of almost 2/3 of HGIEN or early malignancies in our series highlights the importance of a histopathological ’en bloc’ specimen for rectal lesions ⬎3 cm. The low local recurrence rate of 0-3% underlines the potential value of the technique.
www.giejournal.org
Tu1527 The Detection of Polyps and Advanced Lesions in HIV Infected Individuals During Colonoscopy Alexander Schlachterman, Ayaz Matin, David Oustecky, Scott Naples, Daniel A. Ringold Medicine, Drexel University College of Medicine, Philadelphia, PA Background: As HIV infected patients live longer, colonoscopies for both screening and symptomatic patients are performed more often. Compared to controls, non-AIDS defining malignancies are more prevalent in HIV patients. It is not known if the development of colonic neoplasia occurs at a higher rate or at a younger age in HIV infected patients. Methods: We conducted a retrospective study to investigate the prevalence of polyps in HIV patients detected on colonoscopy from 2000-10 at an inner city tertiary care center. These patients underwent colonoscopy either for screening, surveillance or symptoms. Age, sex, symptoms and CD4 count were recorded. Size and histology of both benign and neoplastic polyps were collected. Advanced neoplasms were defined as an adenoma ⬎10mm or any lesion with high-grade dysplasia(HGD), villous histology or carcinoma. A mixed control group without HIV was used for comparison. Results: A total of 319 HIV patients underwent colonoscopy; the mean age of these patients was 51.5 y and 92 were over 50y. There were 209 men and 110 women. 31 of 209 men and 14 of 110 women had polyps(17.4% vs. 12.7%, p⫽ 0.73). The overall neoplastic polyp detection rate in HIV patients was 6.6%, compared to 27.9% in the control group(p⫽⬍0.01 ). Advanced neoplastic lesions were seen in 11 HIV patients(3.5%). In the subgroup of those patients with neoplastic lesions, 52.4%(11/21) had advanced neoplasms, including 4 cancers and 1 HGD. In comparison, the control group had 15/48 advanced neoplasms(31.3%, p⫽0.11). A total of 93 polyps were found in 47 individuals. Of those individuals with any lesion found on colonoscopy, 32% were women and 68% were men(p⫽0.74). 23.4% of neoplasms were found to be advanced neoplasms in the HIV patients compared to 18.3% in the control group(p⫽0.33). The rate of neoplasia detection among patients over 50(n⫽148, mean⫽ 56.7y) was 22.9%. The rate of neoplasia detection in the under 50 group (n⫽137, mean⫽ 43 y) was 9.4%. The preparation was poor for 75 of the 319(23.5%) HIV patients that had colonoscopy in comparison to 9 of 172 (5.2%) patients without HIV (p⬍0.0001). In a subgroup analysis of patients followed in an HIV specialty care clinic, only 29 of 503 patients(5.7%) over 50 received screening colonoscopy. Conclusions: The frequency of polyp detection in HIV patients is not greater than in the control population. However, a greater proportion of advanced neoplasms were seen in HIV infected patients and HIV infected men had more polyps compared to women, although this was not statistically significant. Amongst HIV patients, a low rate of screening and a high rate of poor preparation were observed in our study. Both of these observations are potential areas for quality improvement.
Tu1528 Missed Colon Cancers: Difference Between Right vs TransverseLeft Colon. Five Year Survey in a Community Hospital Francisco Igea, Sergio Maestro, Antonio Perez Millan, Henar Nuñez, Rosa Eva Madrigal, Esther Saracibar, Javier Barcenilla Complejo Hospitalario de Palencia, Palencia, Spain Background: Missed colon cancers are nowadays a great concern in gastrointestinal endoscopy. Colonoscopy seems to be less protective in rigth colon cancers that in left-transverse side. Some authors denied protective effect of colonoscopy in right colon cancers (1). Aims: To determine if there is any difference between right and Left colon in terms of missed colon cancers. To determine if there is any prottective effect of colonoscopy against right colon cancer by comparing frequence of previous colonoscopy with a healthy control group. Methods: We reviewed all colon cancers diagnosed in our hospital between Jan 2005-Jan 2010. Right was defined by location of tumour between appendix and hepatic angle ( both included), all others were considered lefttransverse. All previous colonoscopies during a 10 year period before diagnosis in those patients were extracted from our database.Our hospital is the only public institution able to do colonoscopy in our province and all endoscopic procedures are collected in a computorized data base since 1995. A control group of patients with a”clean colonoscopy”⫽(No cancer) during 2009 were matched by sex and age 2:1 with the study group. We extracted also all previous colonoscopies in this control group. Missed colon cancer was defined by a previous colonoscopy done within the 3 years period before diagnosis of cancer as in Ontario group(2) Results: 726 colon cancers were found. 416 males/310 females.206 were Right, 510 Left & 10 sinchronic. 1454 controls were extracted. Frequence of previous colonoscopies are summarized in table 1. 2,5% of the patients had a missed colon cancer. There were 4,6% in the right colon vs 1,7% in left transverse P⬍0,05. Previous colonoscopy rate in healthy controls was significantly higher 10,2% p⬍0,05 Conclusions: 1) Missed colon cancers are considerably more frequent in right colon (more than double) 2) It is mandatory to make changes in our practice to improve detection of flat/minimal lesions in right colon 3) Although previous colonoscopy was more frequent in right colon cancer group than in other locations there is still a difference with healthy controls. Protective effect of colonoscopy seems reasonable also in this
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB437
cumbersome due to entrapment in the head of the polyp and risk of slipping off immediately after polypectomy. The latter is particularly frequent there is not enough room for endoloop application due to a short polyp stalk. We report about the use of a simple and safe method combining the use of clips and endoloop. Methods: Patients with large pedunculated polyps (⬎3 cm) were included. We used a prototype therapeutic sigmoidoscope (Olympus, Tokyo, Japan), 80 cm long, equipped with two working channels (2.8 mm and 3.7 mm, respectively). One working channel has an up/down elevator. Using a “twohanded” approach, 2 clips were initially placed at the base of the stalk, on two opposite sides. In order to fix it securely, the endoloop was then placed at the base of the stalk below the two clips. To facilitate the procedure the endoloop was opened through one channel, the polyp was grabbed through the other channel by a tripod and then pulled inside the endoloop. Thus, the endoloop was subsequently firmly secured at the base of the stalk. If necessary, the same procedure was repeated to capture the polyp within the diathermic snare for resection. The procedures were performed under conscious sedation using meperidine and midazolam. Results: Twenty-five pedunculated polyps in 24 patients (13 F, 11 M; median age 59) were resected with the “clip and loop” technique. It was possible to place an endoloop successfully below the clips at the basis of the stalk and perform a resection in all cases. No major complication occurred. Particularly, in no case the endoloop fell off after resection. In comparison to the previous cases performed with the endoloop only, the success rate in terms of correct and durable endoloop placement was higher (100% vs. 84%). Conclusions: Application of endoloop below the clips is feasible and safe and prevents slipping off of the endoloop after polypectomy. Use of a combination of clips and endoloop is an effective prophylactic measure to prevent bleeding after polypectomy of large pedunculated polyps, also when the stalk is short.
Tu1526 Endoscopic Submucosal Dissection (ESD) up to 11 cm for 54 Large Laterally Spreading Tumors or Local Recurrencies in the Recto-Sigmoid Juergen Hochberger, Guenter Wilhelms, Martin Froelich, Detlev Menke, Edris Wedi, Karl-Friedrich Buerrig, Elena Kruse Gastroenterology, Intervent. Endoscopy, St. Bernward Hospital, Hildesheim, Germany Piecemeal-EMR of lateral spreading tumors (LST) in the colo-rectum over 2 cm is associated with a recurrence rate of about 15% (3-32%). Adenomata have a sizedependent progressive risk of malignant transformation especially over 2 cm. ESD provides an ’en bloc’ specimen allowing a precise vertical and lateral histopathological evaluation and promises a low recurrence rate (0-3%). However, ESD experience in the ’Western World’ is limited compared to published large Japanese series.Patients and Method: March 28, 2006 to November 11, 2010 52 patients were treated with 54 ESDs (1x 3ESDs): 71 y (4990 y); 19 f, 34 m; ASA 2-4 with a flat or elevated polyp in the recto-sigmoid over 2 cm. In 1 patient 3 lesions were resected in 2 ESD sessions. 11/52 patients (21%) had a previous local treatment (7x EMR; 4x surgical full-thickness resection). Location: 31/54 (57%) in the distal, 16 (30%) in the middle and 7(13%) in the proximal rectum or sigma. Results: 46 of 54 lesions could be resected macroscopically ’en bloc’ (85%); histologically a clear adenoma/tumor-free margin was present in 34/54 (63%). In 5 ESDs (9%) a clear statment was not possible due to termal artefacts. The macro-pathological size of the formalinfixed specimen pinned on kork ranged from 2.2 cm to 11 cm for the largest diameter (48/54 specimen ⱖ3 cm)Histopathology revealed foci of adenocarcinoma in 6/54 (11%), foci of a neuroendocrine tumor in 1 (1.85%; net), lymphoma in 1. In 46/54 specimen histology showed tubulovillous (44) or villous (2) adenomata (37% LG-IEN; 24/44⫽ 44% HG-IEN). 32/54 (59%) of all lesions showed HG-IEN or cancer/lym/net. However a referral bias seems probable.Median follow-up was 301 days (20-1,708 days). Two patients died unrelated to the resection.4 pT1 cancers underwent surgery due L⫹; V⫹/G3; R1 (2 cases). The neuroendocrine tumor due to V⫹, R1 G3. All other cases were followed conservatively by endoscopy and telephone interviews. Complications: 3 perforations due to wall damage during or following ESD (5.6 %) managed conservatively. In one case ESD was accomponied by a rare colonic methan gas explosion and the patient operated for safety reasons (prior ESD specimen R0). 5 minor bleedings (9%) occured, no patient needed blood transfusion (0%). Proven recurrence macroscopically and in local biopsies was 0%. In one case (1.85%) a secondary 6 mm lesion close to the scar was found after 12 month and resected (R0, LGD tv adenoma). Conclusions: ESD up to 11 cm for large mucosal lesions or local recurrencies after EMR/ surgical full-thickness resection in the rectosigmoid is feasable in the western endoscopic world. A rate of almost 2/3 of HGIEN or early malignancies in our series highlights the importance of a histopathological ’en bloc’ specimen for rectal lesions ⬎3 cm. The low local recurrence rate of 0-3% underlines the potential value of the technique.
www.giejournal.org
Tu1527 The Detection of Polyps and Advanced Lesions in HIV Infected Individuals During Colonoscopy Alexander Schlachterman, Ayaz Matin, David Oustecky, Scott Naples, Daniel A. Ringold Medicine, Drexel University College of Medicine, Philadelphia, PA Background: As HIV infected patients live longer, colonoscopies for both screening and symptomatic patients are performed more often. Compared to controls, non-AIDS defining malignancies are more prevalent in HIV patients. It is not known if the development of colonic neoplasia occurs at a higher rate or at a younger age in HIV infected patients. Methods: We conducted a retrospective study to investigate the prevalence of polyps in HIV patients detected on colonoscopy from 2000-10 at an inner city tertiary care center. These patients underwent colonoscopy either for screening, surveillance or symptoms. Age, sex, symptoms and CD4 count were recorded. Size and histology of both benign and neoplastic polyps were collected. Advanced neoplasms were defined as an adenoma ⬎10mm or any lesion with high-grade dysplasia(HGD), villous histology or carcinoma. A mixed control group without HIV was used for comparison. Results: A total of 319 HIV patients underwent colonoscopy; the mean age of these patients was 51.5 y and 92 were over 50y. There were 209 men and 110 women. 31 of 209 men and 14 of 110 women had polyps(17.4% vs. 12.7%, p⫽ 0.73). The overall neoplastic polyp detection rate in HIV patients was 6.6%, compared to 27.9% in the control group(p⫽⬍0.01 ). Advanced neoplastic lesions were seen in 11 HIV patients(3.5%). In the subgroup of those patients with neoplastic lesions, 52.4%(11/21) had advanced neoplasms, including 4 cancers and 1 HGD. In comparison, the control group had 15/48 advanced neoplasms(31.3%, p⫽0.11). A total of 93 polyps were found in 47 individuals. Of those individuals with any lesion found on colonoscopy, 32% were women and 68% were men(p⫽0.74). 23.4% of neoplasms were found to be advanced neoplasms in the HIV patients compared to 18.3% in the control group(p⫽0.33). The rate of neoplasia detection among patients over 50(n⫽148, mean⫽ 56.7y) was 22.9%. The rate of neoplasia detection in the under 50 group (n⫽137, mean⫽ 43 y) was 9.4%. The preparation was poor for 75 of the 319(23.5%) HIV patients that had colonoscopy in comparison to 9 of 172 (5.2%) patients without HIV (p⬍0.0001). In a subgroup analysis of patients followed in an HIV specialty care clinic, only 29 of 503 patients(5.7%) over 50 received screening colonoscopy. Conclusions: The frequency of polyp detection in HIV patients is not greater than in the control population. However, a greater proportion of advanced neoplasms were seen in HIV infected patients and HIV infected men had more polyps compared to women, although this was not statistically significant. Amongst HIV patients, a low rate of screening and a high rate of poor preparation were observed in our study. Both of these observations are potential areas for quality improvement.
Tu1528 Missed Colon Cancers: Difference Between Right vs TransverseLeft Colon. Five Year Survey in a Community Hospital Francisco Igea, Sergio Maestro, Antonio Perez Millan, Henar Nuñez, Rosa Eva Madrigal, Esther Saracibar, Javier Barcenilla Complejo Hospitalario de Palencia, Palencia, Spain Background: Missed colon cancers are nowadays a great concern in gastrointestinal endoscopy. Colonoscopy seems to be less protective in rigth colon cancers that in left-transverse side. Some authors denied protective effect of colonoscopy in right colon cancers (1). Aims: To determine if there is any difference between right and Left colon in terms of missed colon cancers. To determine if there is any prottective effect of colonoscopy against right colon cancer by comparing frequence of previous colonoscopy with a healthy control group. Methods: We reviewed all colon cancers diagnosed in our hospital between Jan 2005-Jan 2010. Right was defined by location of tumour between appendix and hepatic angle ( both included), all others were considered lefttransverse. All previous colonoscopies during a 10 year period before diagnosis in those patients were extracted from our database.Our hospital is the only public institution able to do colonoscopy in our province and all endoscopic procedures are collected in a computorized data base since 1995. A control group of patients with a”clean colonoscopy”⫽(No cancer) during 2009 were matched by sex and age 2:1 with the study group. We extracted also all previous colonoscopies in this control group. Missed colon cancer was defined by a previous colonoscopy done within the 3 years period before diagnosis of cancer as in Ontario group(2) Results: 726 colon cancers were found. 416 males/310 females.206 were Right, 510 Left & 10 sinchronic. 1454 controls were extracted. Frequence of previous colonoscopies are summarized in table 1. 2,5% of the patients had a missed colon cancer. There were 4,6% in the right colon vs 1,7% in left transverse P⬍0,05. Previous colonoscopy rate in healthy controls was significantly higher 10,2% p⬍0,05 Conclusions: 1) Missed colon cancers are considerably more frequent in right colon (more than double) 2) It is mandatory to make changes in our practice to improve detection of flat/minimal lesions in right colon 3) Although previous colonoscopy was more frequent in right colon cancer group than in other locations there is still a difference with healthy controls. Protective effect of colonoscopy seems reasonable also in this
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB437