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⁎4489 Patient tolerance of unsedated colonoscopy vs. flexible sigmoidoscopy in colon cancer screening.
*4489 PATIENT TOLERANCE OF UNSEDATED COLONOSCOPY VS. FLEXIBLE SIGMOIDOSCOPY IN COLON CANCER SCREENING. Robert Daniel Thomson, Erik W. Springer, Peter B. Anderson, Dartmouth Hitchcock Med Ctr, Lebanon, NH. BACKGROUND: Colonoscopy has not been utilized in screening programs of average risk adults because of higher costs (physician time, conscious sedation with intensive monitoring, and patient recovery time) and risks associated with conscious sedation. Unsedated colonoscopy has not been employed because of concern for patient comfort. It is important to make a screening procedure tolerable enough that patients will return for future screening exams. AIMS: Randomized, single blinded study of patient tolerance of unsedated colonoscopy with pediatric colonoscopes in a colon cancer screening program. METHODS/PATIENTS: 140 patients referred to our center for routine screening flexible sigmoidoscopy were randomized to standard 70 cm flexible sigmoidoscopes (group 1), 160 cm pediatric colonoscopes inserted to a maximum of 70 cm (group 2), or 160 cm pediatric colonoscopes to full insertion (group 3). Exams were continued until above insertion points or the endoscopist determined patient discomfort was sufficient to warrant discontinuation. Bowel prep consisted of Fleets phosphasoda and bisacodyl. Procedures were performed by staff gastroenterologists. Patient discomfort was assessed immediately after the procedure with a visual analog scale of 1 to 10. Secondary endpoints were depth of scope insertion, exam duration, and patient willingness to undergo future screening endoscopies. RESULTS: As seen in the table, more colon was visualized in patients randomized to colonoscopy (group 3) with comparable discomfort and slightly longer exam duration. In group 3, 8 patients (19%) had complete colonoscopies to the cecum. There was no significant difference in refusal of future exams among the groups. CONCLUSION: Unsedated exams by experienced endoscopists using pediatric colonoscopes provide greater visualization of the colon compared to standard flexible sigmoidoscopes, with minimal difference in patient comfort or exam duration.
Group 1 (53 pts) 2 (45 pts) 3 (42 pts)
Scope Depth (cm)
Discomfort Scale (1-10)
Time (minutes)
Refused Re-scope
53.4 53.4 71.3
5.1 4.8 5.9
4.3 4.9 6.7
2 of 53 1 of 45 2 of 42
*4490 SMALL FLAT COLORECTAL CANCER: EXPERIENCE IN 870 CONSECUTIVE COLONOSCOPIES. Noriko Suzuki, Brian P. Saunders, Ian C. Talbot, Ian Tomlinson, Elinor Sawyer, Robyn L. Ward, Jim C. Brooker, Syed G. Shah, Christopher B. Williams, St Mark’s Hosp, London, United Kingdom; Imperial Cancer Research Fund, London, United Kingdom; St Vincent’s Hosp, Darlinghust, Australia. INTRODUCTION & METHOD Flat type colorectal cancers have been comprehensively described in the Japanese literature but are thought to occur only rarely in Western countries. We reviewed one endoscopist’s experience, at a UK centre, in detecting these lesions over a defined period. SUBJECT & RESULT Between Feb.1997 and Oct.1998, one experienced colonoscopist (BPS) performed 870colonoscopies at St Mark’s Hospital. 45 cases of colonic cancer were found, of which 5 cases (3 male, 2female, mean age 69yrs) were early, flat cancers(11%). Only 1 patient had symptoms (bleeding +pain) directly attributable to the early cancer. Two patients were undergoing surveillance after cancer resection and 1 examination because of previous adenomas. Cancers were located as follows, sigmoid colon 2, transverse colon 1, ascending colon 1, hepatic flexure 1. Size was between 8-15 mm (mean 11mm). Dye-spray was used to define each lesion. Macroscopic appearances, by Kudo’s classification, three cases were IIc+IIa, one IIa+IIc and one IIa. In no cases was endoscopic resection attempted.All cases had open curative resection, proved histologically to be invasive cancers with no adenomatous component(Dukes A and Jass classification 1). Molecular analysis including APC, P53 and Kras mutation are undertaken. CONCLUSION Small, flat type colonic cancer is a more frequent finding in Western patients than has been previously reported. The lesion found in this study support the possibility of de-novo caricinogenesis occuring in some patients.
VOLUME 51, NO. 4, PART 2, 2000
*4491 USE OF A SHORTER WAVELENGTH AUTOFLUORESCENCE BAND TO SEPARATE ADENOMATOUS FROM HYPERPLASTIC POLYPS OF THE COLON. Bhaskar Banerjee, Sangeeta Agarwal, Brent Miedema, Rodney Perez, Holekere R. Chandrasekhar, Washington Univ, St Louis, MO; Univ of Missouri, Columbia, MO; Universwity of Missouri, Columbia, MO. INTRODUCTION: The majority of work on autofluorescence has been at emission wavelengths greater than 450 nm. A short wavelentgh emission band was investigated to see if it could distinguish hyperplastic from adenomatous polyps of the colon. METHODS: Endoscopically obtained tissue samples were snap frozen in liquid Nitrogen and stored at -70 Celcius. For each specimen, a sample of normal colonic mucosa from the same patient served as control. Prior to spectroscopy, all samples were thawed over ice and moistened in PBS at pH of 7.4. A spectrofluorometer with a Xenon lamp and excitation and emission spectrometers (Shimatzu RF- 5301 PC Columbia, MD)was used, with a specially constructed tissue holder placed in its measuring chamber. Tissue samples were excited at wavelengts below 350 nm and the maximum intensity of an emission peak below 450 nm digitally recorded. Intensity in arbitrary units (y- axis) were plotted against wavelength (x- axis). All tissue samples were fixed in Formalin and submitted for histology. The emission intensities of hyperplastic polyps (n= 15) and adenomatous polyps (n= 22) were expressed as a ratio of the corresponding fluorescence intensity of normal colonic mucosa (n= 37) in each patient. RESULTS: The ratios of mean emission intensity ± SE were: 1.35 ± 0.07 (hyperplastic) and 2.22 ± 0.12 (adenomatous). The difference between groups (unpaired t test) was significant (p ≤ 0.0001). CONCLUSIONS: The intensity of this emission band increses with adenomatous change, with significant separation between histologic groups. The use of this autofluorescence band during screening flexible sigmoidoscopy may help to distinguish adenomatous polyps from hyperplastic ones in real time. The need to wait for biopsy results could be avoided. Patients with hyperplastic polyps could be advised not to have a colonoscopy at the end of screening flexible sigmoidoscopy, without the need to wait for biopsy results. Unlike chromoendoscopy, this technique will not require any dye or exogenous chemicals. Further work using a hand held, portable fiberoptic spectrometer is being planned.
*4492 DEPRESSED TYPE EARLY COLORECTAL CANCER. Hiroshi Kashida, Shinichi Nishiuma, Hiroshi Tei, Naoya Kimoto, Toyokazu Fukunaga, Akihiko Okada, Masahiro Hirasa, Yasuyoshi Ibuki, Akio Orino, Kobe City Gen Hosp, Kobe, Japan. Background: Depressed colorectal lesions are believed, at least in Japan, to play an important role in colorectal carcinogenesis. Ten years ago they were considered extremely rare, but recently more and more similar cases have been found not only in the Orient but also in the West. Aims: To clarify the characteristics of depressed colorectal lesions, comparing them with those of protruded or flat polyps. Methods: During the period from April 1996 to Sep 1999, 4072 colorectal adenomas and cancers were detected by total colonoscopy in our institute. The patients presented with symptoms and/or signs such as bloody stool, fecal occult blood, or polyps detected by barium enema study. Some of them underwent the colonoscopy as a regular check-up after polypectomy or colectomy. The colonoscopic examinations were done using magnifying scopes (Olympus 200Z), with frequent spraying of indigo carmine dye. Results: The lesions were divided into three groups; protruded polyps (2006), flat adenomas (1973), and small depressed lesions (93). The number of colorectal cancer was 476; Dukes A 226, Dukes B 151, Dukes C 99. The rates of invasive cancer among protruded polyps were 0.2% in lesions from 5 to 9 mm in diameter, 1.7% in 1014mm, 4.0% in 15-19mm, and 7.3% in 20-29mm. The respective rates among the depressed lesions were 33%, 64%, 75%, and 100%. Thirteen of the depressed lesions were accompanied by large polyps (including six colon cancers) which were considered to be causing the symptoms or signs leading to the colonoscopic examination. In order to detect and diagnose small depressed lesions, chromoscopy and magnifying colonoscopy were indispensable. Conclusion: Depressed lesions of colorectum are more malignant than protruded or flat polyps. They do not present any specific symptoms or signs but tend to be associated with large polyps or cancers. They are detected only by the eyes of the examiners who are familiar with such lesions.
GASTROINTESTINAL ENDOSCOPY
AB149
Group 1 (53 pts) 2 (45 pts) 3 (42 pts)
Scope Depth (cm)
Discomfort Scale (1-10)
Time (minutes)
Refused Re-scope
53.4 53.4 71.3
5.1 4.8 5.9
4.3 4.9 6.7
2 of 53 1 of 45 2 of 42
*4490 SMALL FLAT COLORECTAL CANCER: EXPERIENCE IN 870 CONSECUTIVE COLONOSCOPIES. Noriko Suzuki, Brian P. Saunders, Ian C. Talbot, Ian Tomlinson, Elinor Sawyer, Robyn L. Ward, Jim C. Brooker, Syed G. Shah, Christopher B. Williams, St Mark’s Hosp, London, United Kingdom; Imperial Cancer Research Fund, London, United Kingdom; St Vincent’s Hosp, Darlinghust, Australia. INTRODUCTION & METHOD Flat type colorectal cancers have been comprehensively described in the Japanese literature but are thought to occur only rarely in Western countries. We reviewed one endoscopist’s experience, at a UK centre, in detecting these lesions over a defined period. SUBJECT & RESULT Between Feb.1997 and Oct.1998, one experienced colonoscopist (BPS) performed 870colonoscopies at St Mark’s Hospital. 45 cases of colonic cancer were found, of which 5 cases (3 male, 2female, mean age 69yrs) were early, flat cancers(11%). Only 1 patient had symptoms (bleeding +pain) directly attributable to the early cancer. Two patients were undergoing surveillance after cancer resection and 1 examination because of previous adenomas. Cancers were located as follows, sigmoid colon 2, transverse colon 1, ascending colon 1, hepatic flexure 1. Size was between 8-15 mm (mean 11mm). Dye-spray was used to define each lesion. Macroscopic appearances, by Kudo’s classification, three cases were IIc+IIa, one IIa+IIc and one IIa. In no cases was endoscopic resection attempted.All cases had open curative resection, proved histologically to be invasive cancers with no adenomatous component(Dukes A and Jass classification 1). Molecular analysis including APC, P53 and Kras mutation are undertaken. CONCLUSION Small, flat type colonic cancer is a more frequent finding in Western patients than has been previously reported. The lesion found in this study support the possibility of de-novo caricinogenesis occuring in some patients.
VOLUME 51, NO. 4, PART 2, 2000
*4491 USE OF A SHORTER WAVELENGTH AUTOFLUORESCENCE BAND TO SEPARATE ADENOMATOUS FROM HYPERPLASTIC POLYPS OF THE COLON. Bhaskar Banerjee, Sangeeta Agarwal, Brent Miedema, Rodney Perez, Holekere R. Chandrasekhar, Washington Univ, St Louis, MO; Univ of Missouri, Columbia, MO; Universwity of Missouri, Columbia, MO. INTRODUCTION: The majority of work on autofluorescence has been at emission wavelengths greater than 450 nm. A short wavelentgh emission band was investigated to see if it could distinguish hyperplastic from adenomatous polyps of the colon. METHODS: Endoscopically obtained tissue samples were snap frozen in liquid Nitrogen and stored at -70 Celcius. For each specimen, a sample of normal colonic mucosa from the same patient served as control. Prior to spectroscopy, all samples were thawed over ice and moistened in PBS at pH of 7.4. A spectrofluorometer with a Xenon lamp and excitation and emission spectrometers (Shimatzu RF- 5301 PC Columbia, MD)was used, with a specially constructed tissue holder placed in its measuring chamber. Tissue samples were excited at wavelengts below 350 nm and the maximum intensity of an emission peak below 450 nm digitally recorded. Intensity in arbitrary units (y- axis) were plotted against wavelength (x- axis). All tissue samples were fixed in Formalin and submitted for histology. The emission intensities of hyperplastic polyps (n= 15) and adenomatous polyps (n= 22) were expressed as a ratio of the corresponding fluorescence intensity of normal colonic mucosa (n= 37) in each patient. RESULTS: The ratios of mean emission intensity ± SE were: 1.35 ± 0.07 (hyperplastic) and 2.22 ± 0.12 (adenomatous). The difference between groups (unpaired t test) was significant (p ≤ 0.0001). CONCLUSIONS: The intensity of this emission band increses with adenomatous change, with significant separation between histologic groups. The use of this autofluorescence band during screening flexible sigmoidoscopy may help to distinguish adenomatous polyps from hyperplastic ones in real time. The need to wait for biopsy results could be avoided. Patients with hyperplastic polyps could be advised not to have a colonoscopy at the end of screening flexible sigmoidoscopy, without the need to wait for biopsy results. Unlike chromoendoscopy, this technique will not require any dye or exogenous chemicals. Further work using a hand held, portable fiberoptic spectrometer is being planned.
*4492 DEPRESSED TYPE EARLY COLORECTAL CANCER. Hiroshi Kashida, Shinichi Nishiuma, Hiroshi Tei, Naoya Kimoto, Toyokazu Fukunaga, Akihiko Okada, Masahiro Hirasa, Yasuyoshi Ibuki, Akio Orino, Kobe City Gen Hosp, Kobe, Japan. Background: Depressed colorectal lesions are believed, at least in Japan, to play an important role in colorectal carcinogenesis. Ten years ago they were considered extremely rare, but recently more and more similar cases have been found not only in the Orient but also in the West. Aims: To clarify the characteristics of depressed colorectal lesions, comparing them with those of protruded or flat polyps. Methods: During the period from April 1996 to Sep 1999, 4072 colorectal adenomas and cancers were detected by total colonoscopy in our institute. The patients presented with symptoms and/or signs such as bloody stool, fecal occult blood, or polyps detected by barium enema study. Some of them underwent the colonoscopy as a regular check-up after polypectomy or colectomy. The colonoscopic examinations were done using magnifying scopes (Olympus 200Z), with frequent spraying of indigo carmine dye. Results: The lesions were divided into three groups; protruded polyps (2006), flat adenomas (1973), and small depressed lesions (93). The number of colorectal cancer was 476; Dukes A 226, Dukes B 151, Dukes C 99. The rates of invasive cancer among protruded polyps were 0.2% in lesions from 5 to 9 mm in diameter, 1.7% in 1014mm, 4.0% in 15-19mm, and 7.3% in 20-29mm. The respective rates among the depressed lesions were 33%, 64%, 75%, and 100%. Thirteen of the depressed lesions were accompanied by large polyps (including six colon cancers) which were considered to be causing the symptoms or signs leading to the colonoscopic examination. In order to detect and diagnose small depressed lesions, chromoscopy and magnifying colonoscopy were indispensable. Conclusion: Depressed lesions of colorectum are more malignant than protruded or flat polyps. They do not present any specific symptoms or signs but tend to be associated with large polyps or cancers. They are detected only by the eyes of the examiners who are familiar with such lesions.
GASTROINTESTINAL ENDOSCOPY
AB149