- Email: [email protected]
1142 The Impact of Carbon Dioxide Insufflation on Post-Procedural Outcomes After Endoscopic Resection of Large Colonic Lesions: A Prospective Cohort Study
Abstracts
in total). The assessors were then requested to grade these images with the same classification. The overall Accuracy (Acc), Sensitivity (Sn), Specificity (Sp), Positive Predictive Value (PPV), Negative Predictive Value (NPV) of WLE-z, NBI-z and the combination was then determined. Results: A total of 4050 images were available for evaluation. The assessors were able to grade 3370 images with confidence (83.2%). The overall Acc for WLE-z and NBI-z was 87.1% and 88.7% respectively. When images from the two modalities were placed side by side, the Acc increased to 90.3%. The Sn, Sp, PPV, and NPV of WLE-z was 48%, 92%, 45%, 93% whilst with NBI-z, this improved to 89%, 89%, 56%, 98% respectively. When both imaging modalities were viewed together, this improved further to 93%, 90%, 61%, and 99%. Conclusion: The high NPV (99%) when both WLE-z and NBI-z were used simultaneously indicates that regular appearing areas which are diagnosed with confidence can effectively be left alone and not biopsied. This approach could potentially lead to a paradigm shift of how patients with BE are surveyed and may enable random 4 quadrant biopsies to be abandoned altogether.
1141 Clinicopathological Features of Depressed-Type Early Colorectal Carcinomas Shin-Ei Kudo*1, Shingo Matsudaira1, Hideyuki Miyachi1, Nobunao Ikehara1, Yoshiki Wada1, Takemasa Hayashi1, Toshihisa Hosoya1, Kunihiko Wakamura1, Hirotaka Nishiwaki1, Tetsuhiro Kakimoto1, Shomei Ryozawa1, Fuyuhiko Yamamura1, Kazuo Ohtsuka1, Shigeharu Hamatani2 1 Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan; 2Department of Pathology, Showa University Northern Yokohama Hospital, Yokohama, Japan Background and Aims: Recently, the existence of depressed-type early colorectal carcinomas has been revealed, and an increasing number of such lesions have been reported. Depressed-type lesions are considered to emerge directly from the normal epithelium not via adenomas. These are called “de novo” carcinomas. The aim is to clarify the clinicopathological features of depressed-type early colorectal carcinomas. Method: A total of 16071 colorectal carcinomas excluding advanced carcinomas have been resected endoscopically or surgically in our center from April 2001 to Jun 2011.Of these, 717 submucosal invasive colorectal carcinomas were included. According to the morphological development classification (modified Paris classification), 156 lesions (21.1%) were depressed type, 214 lesions (32.4%) were flat type and 321 lesions (46.6%) were protruded type. We analyzed the clinicopathological features (gender, age, location, rate of submucosal invasion, vessel permeation, sprouting, disappearance of muscularis mucosae and residual adenomatous component) of these lesions. Results: There were no significant differences in gender (Male:Female; 1.95:1 in depressed type, 2.00:1 in flat type and 1.73:1 in protruded type) and age distribution (mean age; 65.9⫾11 years old in depressed type, 67.5⫾10 in flat type and 63.7⫾7.9 in protruded type). There was significant differences as for the location of lesions(proximal colon: distal colon; 1:2.34 in depressed type, 1:1.29 in flat type and 1:6.00 in protruded type.) The rate of submucosal invasion was 63.4% in depressed type, 3.8% in flat type and 3.4% in protruded type. The rate of submucosal invasion of depressed-type lesions under 5mm in diameter was 9.6%, and that was 59.2% in those from 6mm to 10mm, and 77.0% in those from 11mm to 15mm. In contrast, the invasive rates of flat-type and protruded-type lesions under 5mm in diameter were 0.00% and 0.02% respectively. The rate of vessel permeation was 63.7%, 31.3% and 39.3%, that of sprouting was 37.1%, 14.1% and 16.2%, that of disappearance of muscularis mucosae was 91.8%, 68.9% and 88.2% and that of residual adenomatous component was 2.6%, 50.5% and 53.3% for depressed, flat and protruded-type lesions respectively. Except for the disappearance of muscularis mucosae, these were significantly higher in the depressed-type group compared with the other groups. Conclusions: Depressedtype early colorectal carcinomas tend to invade submucosal layer and grow downward even when they were small in size. It suggests that they follow a growth pathway different from “adenoma-carcinoma sequence.” It is therefore important to reach a well-thought out assessment taking account of the development/progression of colorectal carcinomas.
often results in post procedure admission (PPA). Carbon dioxide (CO2) insufflation has been shown to reduce pain scores after routine colonoscopy, but an influence on more critical outcomes such as PPA has not been shown. Methods: Data from a large, prospective, single centre cohort of EMR for colonic LSTs ⱖ20mm was analysed (June 2008- November 2011). Data collection included patient and polyp characteristics, post-procedural pain, perforation rates, and PPA. EMR was only performed with air insufflation from June 2008March 2010 and after a trial period only CO2 from August 2010-November 2011. Results: EMR was performed on 575 lesions ⱖ 20mm, 228 with CO2 insufflation. Mean lesion size was 36.5mm (range 20-100). Comparisons between the groups are outlined in table 1. Lesion size, morphology and distribution was similar in both groups. The use of CO2 was associated with a 62% decrease in PPA rate from 8.9% to 3.4% (p⫽0.01). This was mainly due to reduced admissions for pain with a 82% decrease in PPA for pain from 5.7% to 1.0% (p⫽0.006) (table 1). There was no significant difference in the rates of perforation or post EMR bleeding. No significant respiratory complications occurred in either group (including no clinically significant hypercapnia).Multiple logistical regression identified the use of air insufflation, presence of major comorbidity and procedure duration as independent predictors of PPA for any cause and admission for pain. The odds ratio of PPA amongst those receiving CO2 rather than air insufflation after adjusting for duration and co-morbidity remained significant (OR 0.39, 95% CI 0.16 to 0.95, p⫽0.04). The adjusted odds ratio for admission for pain among those receiving CO2 insufflation was highly significant (OR 0.18, 95% CI 0.04 to 0.78, p⫽0.02. Conclusions: CO2 insufflation significantly reduces the need for hospitalisation following EMR of large colonic lesions. This is primarily due to reduced post-procedural pain. The reduction in pain is postulated to be due to reduced luminal distension and consequently reduced tension on the large mucosal defect (figure 1). CO2 insufflation should be routinely used during EMR of large colonic lesions. Table 1. Patient and lesion characteristics and admission rates
Patients Lesions Admission Admission for pain Age (years) Lesion size (mean) Right colon Mean EMR time Successful EMR Perforation
AIR
CO2
p
334 347 28 (8.9%) 18 (5.7%) 69.1 35.7mm 203 (58.5%) 24.9 mins 292 (88%) 4 (1.1%)
190 228 7 (3.4%) 2 (1.0%) 67.8 37.5mm 143 (63%) 21.8 mins 203 (93%) 1 (0.5%)
0.01 0.006 0.15 0.17 0.28 0.12 0.07 0.65
Figure 1. Proposed mechanism for CO2 insufflation to reduce pain post EMR. 1142 The Impact of Carbon Dioxide Insufflation on Post-Procedural Outcomes After Endoscopic Resection of Large Colonic Lesions: A Prospective Cohort Study Milan S. Bassan*, Michael J. Bourke, Bronte A. Holt, Alan Moss, Stephen J. Williams, Rebecca Sonson Gastroenterology and Hepatology, Westmead Hospital, Wentworthville, NSW, Australia Introduction: Endoscopic mucosal resection (EMR) for large colonic lesions is a safe and effective outpatient treatment. Post procedural pain has a number of possible aetiologies. It creates concern for possible perforation and serositis and
www.giejournal.org
Volume 75, No. 4S : 2012
GASTROINTESTINAL ENDOSCOPY
AB176
in total). The assessors were then requested to grade these images with the same classification. The overall Accuracy (Acc), Sensitivity (Sn), Specificity (Sp), Positive Predictive Value (PPV), Negative Predictive Value (NPV) of WLE-z, NBI-z and the combination was then determined. Results: A total of 4050 images were available for evaluation. The assessors were able to grade 3370 images with confidence (83.2%). The overall Acc for WLE-z and NBI-z was 87.1% and 88.7% respectively. When images from the two modalities were placed side by side, the Acc increased to 90.3%. The Sn, Sp, PPV, and NPV of WLE-z was 48%, 92%, 45%, 93% whilst with NBI-z, this improved to 89%, 89%, 56%, 98% respectively. When both imaging modalities were viewed together, this improved further to 93%, 90%, 61%, and 99%. Conclusion: The high NPV (99%) when both WLE-z and NBI-z were used simultaneously indicates that regular appearing areas which are diagnosed with confidence can effectively be left alone and not biopsied. This approach could potentially lead to a paradigm shift of how patients with BE are surveyed and may enable random 4 quadrant biopsies to be abandoned altogether.
1141 Clinicopathological Features of Depressed-Type Early Colorectal Carcinomas Shin-Ei Kudo*1, Shingo Matsudaira1, Hideyuki Miyachi1, Nobunao Ikehara1, Yoshiki Wada1, Takemasa Hayashi1, Toshihisa Hosoya1, Kunihiko Wakamura1, Hirotaka Nishiwaki1, Tetsuhiro Kakimoto1, Shomei Ryozawa1, Fuyuhiko Yamamura1, Kazuo Ohtsuka1, Shigeharu Hamatani2 1 Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan; 2Department of Pathology, Showa University Northern Yokohama Hospital, Yokohama, Japan Background and Aims: Recently, the existence of depressed-type early colorectal carcinomas has been revealed, and an increasing number of such lesions have been reported. Depressed-type lesions are considered to emerge directly from the normal epithelium not via adenomas. These are called “de novo” carcinomas. The aim is to clarify the clinicopathological features of depressed-type early colorectal carcinomas. Method: A total of 16071 colorectal carcinomas excluding advanced carcinomas have been resected endoscopically or surgically in our center from April 2001 to Jun 2011.Of these, 717 submucosal invasive colorectal carcinomas were included. According to the morphological development classification (modified Paris classification), 156 lesions (21.1%) were depressed type, 214 lesions (32.4%) were flat type and 321 lesions (46.6%) were protruded type. We analyzed the clinicopathological features (gender, age, location, rate of submucosal invasion, vessel permeation, sprouting, disappearance of muscularis mucosae and residual adenomatous component) of these lesions. Results: There were no significant differences in gender (Male:Female; 1.95:1 in depressed type, 2.00:1 in flat type and 1.73:1 in protruded type) and age distribution (mean age; 65.9⫾11 years old in depressed type, 67.5⫾10 in flat type and 63.7⫾7.9 in protruded type). There was significant differences as for the location of lesions(proximal colon: distal colon; 1:2.34 in depressed type, 1:1.29 in flat type and 1:6.00 in protruded type.) The rate of submucosal invasion was 63.4% in depressed type, 3.8% in flat type and 3.4% in protruded type. The rate of submucosal invasion of depressed-type lesions under 5mm in diameter was 9.6%, and that was 59.2% in those from 6mm to 10mm, and 77.0% in those from 11mm to 15mm. In contrast, the invasive rates of flat-type and protruded-type lesions under 5mm in diameter were 0.00% and 0.02% respectively. The rate of vessel permeation was 63.7%, 31.3% and 39.3%, that of sprouting was 37.1%, 14.1% and 16.2%, that of disappearance of muscularis mucosae was 91.8%, 68.9% and 88.2% and that of residual adenomatous component was 2.6%, 50.5% and 53.3% for depressed, flat and protruded-type lesions respectively. Except for the disappearance of muscularis mucosae, these were significantly higher in the depressed-type group compared with the other groups. Conclusions: Depressedtype early colorectal carcinomas tend to invade submucosal layer and grow downward even when they were small in size. It suggests that they follow a growth pathway different from “adenoma-carcinoma sequence.” It is therefore important to reach a well-thought out assessment taking account of the development/progression of colorectal carcinomas.
often results in post procedure admission (PPA). Carbon dioxide (CO2) insufflation has been shown to reduce pain scores after routine colonoscopy, but an influence on more critical outcomes such as PPA has not been shown. Methods: Data from a large, prospective, single centre cohort of EMR for colonic LSTs ⱖ20mm was analysed (June 2008- November 2011). Data collection included patient and polyp characteristics, post-procedural pain, perforation rates, and PPA. EMR was only performed with air insufflation from June 2008March 2010 and after a trial period only CO2 from August 2010-November 2011. Results: EMR was performed on 575 lesions ⱖ 20mm, 228 with CO2 insufflation. Mean lesion size was 36.5mm (range 20-100). Comparisons between the groups are outlined in table 1. Lesion size, morphology and distribution was similar in both groups. The use of CO2 was associated with a 62% decrease in PPA rate from 8.9% to 3.4% (p⫽0.01). This was mainly due to reduced admissions for pain with a 82% decrease in PPA for pain from 5.7% to 1.0% (p⫽0.006) (table 1). There was no significant difference in the rates of perforation or post EMR bleeding. No significant respiratory complications occurred in either group (including no clinically significant hypercapnia).Multiple logistical regression identified the use of air insufflation, presence of major comorbidity and procedure duration as independent predictors of PPA for any cause and admission for pain. The odds ratio of PPA amongst those receiving CO2 rather than air insufflation after adjusting for duration and co-morbidity remained significant (OR 0.39, 95% CI 0.16 to 0.95, p⫽0.04). The adjusted odds ratio for admission for pain among those receiving CO2 insufflation was highly significant (OR 0.18, 95% CI 0.04 to 0.78, p⫽0.02. Conclusions: CO2 insufflation significantly reduces the need for hospitalisation following EMR of large colonic lesions. This is primarily due to reduced post-procedural pain. The reduction in pain is postulated to be due to reduced luminal distension and consequently reduced tension on the large mucosal defect (figure 1). CO2 insufflation should be routinely used during EMR of large colonic lesions. Table 1. Patient and lesion characteristics and admission rates
Patients Lesions Admission Admission for pain Age (years) Lesion size (mean) Right colon Mean EMR time Successful EMR Perforation
AIR
CO2
p
334 347 28 (8.9%) 18 (5.7%) 69.1 35.7mm 203 (58.5%) 24.9 mins 292 (88%) 4 (1.1%)
190 228 7 (3.4%) 2 (1.0%) 67.8 37.5mm 143 (63%) 21.8 mins 203 (93%) 1 (0.5%)
0.01 0.006 0.15 0.17 0.28 0.12 0.07 0.65
Figure 1. Proposed mechanism for CO2 insufflation to reduce pain post EMR. 1142 The Impact of Carbon Dioxide Insufflation on Post-Procedural Outcomes After Endoscopic Resection of Large Colonic Lesions: A Prospective Cohort Study Milan S. Bassan*, Michael J. Bourke, Bronte A. Holt, Alan Moss, Stephen J. Williams, Rebecca Sonson Gastroenterology and Hepatology, Westmead Hospital, Wentworthville, NSW, Australia Introduction: Endoscopic mucosal resection (EMR) for large colonic lesions is a safe and effective outpatient treatment. Post procedural pain has a number of possible aetiologies. It creates concern for possible perforation and serositis and
www.giejournal.org
Volume 75, No. 4S : 2012
GASTROINTESTINAL ENDOSCOPY
AB176