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692 Endoscopic Resection of Large Laterally Spreading Rectal Adenomas: EMR Versus Esd
Abstracts
without near-focus in the optical detection of residual neoplasia after EMR in realtime. Methods: This multicenter prospective study started in January 2016 and is ongoing. Consecutive patients undergoing follow-up colonoscopy after a previous EMR of a 20mm colorectal neoplasia were eligible for inclusion. Endoscopists predicted the presence of recurrence and their level of confidence (high or low) based on visual assessment of the previous EMR site subsequently with the following four modalities 1) high-definition white light colonoscopy without and 2) with near-focus, and 3) NBI without and 4) with near-focus. Each EMR-site was biopsied as a reference standard, and histology was assessed by a pathologist blinded to colonoscopy findings. Subsequently, all images were presented in a random order > 3 months after the index procedure to five experienced EMR physicians to check interobserver agreement for all modalities. Negative predictive value (NPV), positive predictive value (PPV), sensitivity, specificity and diagnostic accuracy including 95% confidence intervals were calculated for all diagnostic modalities for the real-time and offline image assessment. Results: Perprotocol107 patients (males: nZ58 [59%], median age: 67 [range: 45-90] years) with 111 scar sites were included, with a median follow-up of 10 (range: 3-70) months. The prevalence of residual neoplasia was 33%. Diagnostic values for all EMR-scar sites and assessed with high confidence are summarized separately for the real-time and offline assessment in table 1 and 2. The interobserver agreement for NBI near-focus was substantial (kappa: 0.81 95%-CI: 0.68-0.94) among five experienced EMR endoscopists (Table 2). Conclusion: These preliminary results suggest a very high NPV and good diagnostic accuracy for all four imaging modalities, with especially a high NPV and substantial interobserver agreement with NBI with near-focus for the optical diagnosis of residual neoplasia when assessed with high confidence in both the real-time and offline evaluation. These advanced imaging modalities may improve real-time decision making in follow-up after colorectal EMR, particularly the avoidance of biopsy.
Diagnostic value of optical detection of residual neoplasia during EMR follow-up All EMR-sites, n[111 NPV (%) PPV, (%) Sensitivity, (%) Specificity, (%) Accuracy, (%) High confidence diagnosis, (%) NPV, (%) PPV, (%) Sensitivity, (%) Specificity, (%) Accuracy, (%)
White light
White light with near-focus
95 82 92 91 91
[88-99] [68-93] [78-98] [81-96] [84-95] 81% 96 [82-100] 93 [77-99] 96 [82-100] 93 [77-99] 96 [90-99]
96 83 92 92 91
[88-99] [68-93] [78-98] [81-96] [84-96] 83% 98 [91-100] 90 [74-98] 97 [82-100] 95 [87-99] 96 [89-99]
NBI
NBI with near-focus
[88-99] [68-93] [78-98] [81-96] [84-95] 82% 98 [91-100] 90 [73-98] 90 [73-98] 95 [87-99] 96 [89-99]
97 [90-100] 83 [69-93 ] 95 [82-99] 91 [81-96] 92 [85-96] 91% 100 [94-100] 84 [68-94] 100 [89-100] 91 [82-97] 94 [87-97]
96 82 92 91 91
[..-.], 95%-confidence interval; n, number of EMR-sites.
Table 2. Diagnostic value of optical detection of residual neoplasia during offline assessment All EMR-images, n[101
White light
White light with nearfocus
NBI
NBI with nearfocus
NPV, (%)
85 [76-92]
85 [75-91]
93 [85-97]
94 [86-98]
PPV, (%) Sensitivity, (%) Specificity, (%) Accuracy, (%) Interobserver agreement, kappa High confidence diagnosis, (%) NPV, (%) PPV, (%) Sensitivity, (%) Specificity, (%) Accuracy, (%) Interobserver agreement, kappa
70 [56-82] 74 [60-85] 82 [72-89] 79 [71-85] 0.55 [0.410.69] 62%
72 [58-84] 74 [60-85] 83 [73-91] 80 [72-86] 0.57 [0.42-0.71]
76 [60-89] 86 [69-95] 88 [79-95] 87 [80-93] 0.72 [0.580.85] 77%
69 [53-82] 89 [73-97] 82 [72-90] 84 [76-90] 0.65 [0.51-0.79]
89 [78-96] 90 [73-98] 81 [64-93] 94 [85-99] 89 [81-95] 0.77 [0.630.91]
83 [71-92] 76 [59-88] 76 [59-88] 83 [71-92] 80 [71-88] 0.59 [0.43-0.76]
96 [88-100] 70 [54-84] 92 [75-99] 92 [82-97] 85 [76-91] 0.68 [0.530.83]
96 [86-100] 82 [64-94] 94 [79-99] 80 [67-89] 92 [ 84-97] 0.81 [0.68-0.94]
68%
80%
[..-..], 95%-confidence interval; n, number of EMR-images
691 Learning Curve Analysis for Colorectal Endoscopic Submucosal Dissection Tomohiko Moriyama*, Motohiro Esaki, Toshifumi Morishita, Yuji Maehata, Takehiro Torisu, Junji Umeno, Atsushi Hirano, Yasuharu Okamoto, Takanari Kitazono Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka-shi, Fukuoka-ken, Japan Background & Aims: Endoscopic submucosal dissection (ESD) for colorectal neoplasm has been shown to be effective. However, colorectal ESD is more technically difficult than colorectal endoscopic mucosal resection (EMR). The primary aim of this study was to determine the number of colorectal ESD procedures that
AB102 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
should be performed to acquire safe and accurate technique. Methods: We have established a multicenter database of gastrointestinal ESD, Kyushu University multicenter ESD database (KYU-MED). All cases undergoing gastrointestinal ESD in 19 participating hospitals were registered to KYU-MED between September 2006 and September 2014. In this database, a total of 560 colorectal ESD procedures performed by 34 endoscopists were registered. Each endosopist had experienced 1 to 112 colorectal ESD procedures. The cases in each endoscopist were divided consecutively into 4 learning period, period 1 (1-20 cases), period 2 (21-40 cases), period 3 (41-60 cases) and period 4 (over 61 cases). To analyze the learning curve, en bloc resection with tumor-free margin (R0 resection) rate, tumor size, procedural time and complication rate were compared among 4 groups. Results: The overall rates of R0 resection and complication were 84.0% (461/560) and 8.0% (45/560), respectively. The R0 resection rate was 77.2% (196/254) in period 1, 78.6% (99/126) in period 2, 91.2% (83/91) in period 3 and 93.3% (83/89) in period 4, respectively (p<0.01). The complication rate was 10.6% (27/254) in period 1, 11.9% (15/126) in period 2, 2.2% (2/91) in period 3 and 1.1% (1/89) in period 4, respectively (p<0.01). Three cases in period 1 underwent surgical operation due to perforation during procedure. Although tumor size was larger in period 3 and 4 compared to period 1 and 2, procedural time was not different among 4 groups. Conclusions: According to the results of this large multicenter study, approximately 40 cases of colorectal ESD should be needed to acquire safe and accurate technique.
692 Endoscopic Resection of Large Laterally Spreading Rectal Adenomas: EMR Versus Esd Hubert H. Nietsch*1,2 1 Div. of Gastroenterology, St. Elisabeth Medical Center, Halle, Germany; 2 Div. of Gastroenterology, Albany Medical College, Albany, NY Aims: Since the advent of screening colonoscopy many more asymptomatic large rectal polyps >5cm in diameter are detected. With the introduction of EMR (endoscopic mucosal resection) and ESD (endoscopic submucosal dissection) we have now endoscopic means to resect those lesions effectively. It is however still unclear whether EMR or ESD is superior in terms of complete resection and safety. Methods: We compare the outcome (perforation, bleeding, complete resection, recurrence rate) in two cohorts of patients with laterally spreading rectal adenomas >5cm who were either treated by EMR or ESD in our center. Results: 62 large laterally spreading rectal adenomas in consecutive patients’ (age 45-84 years) were completely resected endoscopically. ESD en-bloc resection was performed in 23 patients. All other lesions were excised by piecemeal EMR. Prior to resection a careful examination under white light and NBI was performed using the Paris classification. In comparison ESD took about three times as long as EMR (average procedure time 98 min vs 37 min) with comparable intra- and postoperative bleeding rates (5% in each group). No perforations were encountered. All en-bloc ESD specimens were R0 on histology. In one patient deep submucosal invasion of the submucosa (>1000mm) was present. The patient underwent surgical resection 6 weeks after the endoscopy without evidence of remaining tumor or lymph node invasion. The most striking difference in the two groups was seen regarding recurrence of adenomas during 6 months follow-up: 0% in the ESD cohort and 12% in the piecemeal EMR group. All recurrent adenomas after EMR could however be easily resected by snare polypectomy without any further recurrence over the next 12 months. The calculated average equipment cost for ESD (hook knife, dual knife, injectate, transparent cap) was significantly higher compared to EMR (687$ vs. 39$). Conclusion: EMR and ESD are equally effective in resecting large laterally spreading lesions of the rectum despite the higher rate of post-EMR adenoma recurrence which did however not impact the patients overall cure rate after one year. ESD is significantly more time consuming and costly.
693 Cold Piecemeal Endoscopic Mucosal Resection (EMR) for Large Sessile Serrated Colonic Polyps Nicholas J. Tutticci*1,2, David G. Hewett1,2 1 Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia; 2 School of Medicine, University of Queensland, Brisbane, Queensland, Australia Background and Aim: Sessile serrated polyps (SSPs) are important colorectal cancer precursors however the optimal technique for the removal of large lesions remains unknown. Conventional polypectomy has limited efficacy and conventional EMR has a risk of delayed bleeding and perforation. Cold snare resection overcomes these safety concerns, although in practice, piecemeal resection is required for large lesions. In this study, we describe and evaluate a modified cold piecemeal EMR technique for large SSPs. Patients and Methods: Consecutive patients of 2 endoscopists at a single center with one or more 10mm SSPs were included. Patients on anticoagulant/antiplatelet therapy other than aspirin were excluded . Our modified EMR technique comprised: 1) submucosal injection of succinylated gelatin with dilute methylene blue, 2) piecemeal cold snare resection of all visible polyp with a
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without near-focus in the optical detection of residual neoplasia after EMR in realtime. Methods: This multicenter prospective study started in January 2016 and is ongoing. Consecutive patients undergoing follow-up colonoscopy after a previous EMR of a 20mm colorectal neoplasia were eligible for inclusion. Endoscopists predicted the presence of recurrence and their level of confidence (high or low) based on visual assessment of the previous EMR site subsequently with the following four modalities 1) high-definition white light colonoscopy without and 2) with near-focus, and 3) NBI without and 4) with near-focus. Each EMR-site was biopsied as a reference standard, and histology was assessed by a pathologist blinded to colonoscopy findings. Subsequently, all images were presented in a random order > 3 months after the index procedure to five experienced EMR physicians to check interobserver agreement for all modalities. Negative predictive value (NPV), positive predictive value (PPV), sensitivity, specificity and diagnostic accuracy including 95% confidence intervals were calculated for all diagnostic modalities for the real-time and offline image assessment. Results: Perprotocol107 patients (males: nZ58 [59%], median age: 67 [range: 45-90] years) with 111 scar sites were included, with a median follow-up of 10 (range: 3-70) months. The prevalence of residual neoplasia was 33%. Diagnostic values for all EMR-scar sites and assessed with high confidence are summarized separately for the real-time and offline assessment in table 1 and 2. The interobserver agreement for NBI near-focus was substantial (kappa: 0.81 95%-CI: 0.68-0.94) among five experienced EMR endoscopists (Table 2). Conclusion: These preliminary results suggest a very high NPV and good diagnostic accuracy for all four imaging modalities, with especially a high NPV and substantial interobserver agreement with NBI with near-focus for the optical diagnosis of residual neoplasia when assessed with high confidence in both the real-time and offline evaluation. These advanced imaging modalities may improve real-time decision making in follow-up after colorectal EMR, particularly the avoidance of biopsy.
Diagnostic value of optical detection of residual neoplasia during EMR follow-up All EMR-sites, n[111 NPV (%) PPV, (%) Sensitivity, (%) Specificity, (%) Accuracy, (%) High confidence diagnosis, (%) NPV, (%) PPV, (%) Sensitivity, (%) Specificity, (%) Accuracy, (%)
White light
White light with near-focus
95 82 92 91 91
[88-99] [68-93] [78-98] [81-96] [84-95] 81% 96 [82-100] 93 [77-99] 96 [82-100] 93 [77-99] 96 [90-99]
96 83 92 92 91
[88-99] [68-93] [78-98] [81-96] [84-96] 83% 98 [91-100] 90 [74-98] 97 [82-100] 95 [87-99] 96 [89-99]
NBI
NBI with near-focus
[88-99] [68-93] [78-98] [81-96] [84-95] 82% 98 [91-100] 90 [73-98] 90 [73-98] 95 [87-99] 96 [89-99]
97 [90-100] 83 [69-93 ] 95 [82-99] 91 [81-96] 92 [85-96] 91% 100 [94-100] 84 [68-94] 100 [89-100] 91 [82-97] 94 [87-97]
96 82 92 91 91
[..-.], 95%-confidence interval; n, number of EMR-sites.
Table 2. Diagnostic value of optical detection of residual neoplasia during offline assessment All EMR-images, n[101
White light
White light with nearfocus
NBI
NBI with nearfocus
NPV, (%)
85 [76-92]
85 [75-91]
93 [85-97]
94 [86-98]
PPV, (%) Sensitivity, (%) Specificity, (%) Accuracy, (%) Interobserver agreement, kappa High confidence diagnosis, (%) NPV, (%) PPV, (%) Sensitivity, (%) Specificity, (%) Accuracy, (%) Interobserver agreement, kappa
70 [56-82] 74 [60-85] 82 [72-89] 79 [71-85] 0.55 [0.410.69] 62%
72 [58-84] 74 [60-85] 83 [73-91] 80 [72-86] 0.57 [0.42-0.71]
76 [60-89] 86 [69-95] 88 [79-95] 87 [80-93] 0.72 [0.580.85] 77%
69 [53-82] 89 [73-97] 82 [72-90] 84 [76-90] 0.65 [0.51-0.79]
89 [78-96] 90 [73-98] 81 [64-93] 94 [85-99] 89 [81-95] 0.77 [0.630.91]
83 [71-92] 76 [59-88] 76 [59-88] 83 [71-92] 80 [71-88] 0.59 [0.43-0.76]
96 [88-100] 70 [54-84] 92 [75-99] 92 [82-97] 85 [76-91] 0.68 [0.530.83]
96 [86-100] 82 [64-94] 94 [79-99] 80 [67-89] 92 [ 84-97] 0.81 [0.68-0.94]
68%
80%
[..-..], 95%-confidence interval; n, number of EMR-images
691 Learning Curve Analysis for Colorectal Endoscopic Submucosal Dissection Tomohiko Moriyama*, Motohiro Esaki, Toshifumi Morishita, Yuji Maehata, Takehiro Torisu, Junji Umeno, Atsushi Hirano, Yasuharu Okamoto, Takanari Kitazono Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka-shi, Fukuoka-ken, Japan Background & Aims: Endoscopic submucosal dissection (ESD) for colorectal neoplasm has been shown to be effective. However, colorectal ESD is more technically difficult than colorectal endoscopic mucosal resection (EMR). The primary aim of this study was to determine the number of colorectal ESD procedures that
AB102 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
should be performed to acquire safe and accurate technique. Methods: We have established a multicenter database of gastrointestinal ESD, Kyushu University multicenter ESD database (KYU-MED). All cases undergoing gastrointestinal ESD in 19 participating hospitals were registered to KYU-MED between September 2006 and September 2014. In this database, a total of 560 colorectal ESD procedures performed by 34 endoscopists were registered. Each endosopist had experienced 1 to 112 colorectal ESD procedures. The cases in each endoscopist were divided consecutively into 4 learning period, period 1 (1-20 cases), period 2 (21-40 cases), period 3 (41-60 cases) and period 4 (over 61 cases). To analyze the learning curve, en bloc resection with tumor-free margin (R0 resection) rate, tumor size, procedural time and complication rate were compared among 4 groups. Results: The overall rates of R0 resection and complication were 84.0% (461/560) and 8.0% (45/560), respectively. The R0 resection rate was 77.2% (196/254) in period 1, 78.6% (99/126) in period 2, 91.2% (83/91) in period 3 and 93.3% (83/89) in period 4, respectively (p<0.01). The complication rate was 10.6% (27/254) in period 1, 11.9% (15/126) in period 2, 2.2% (2/91) in period 3 and 1.1% (1/89) in period 4, respectively (p<0.01). Three cases in period 1 underwent surgical operation due to perforation during procedure. Although tumor size was larger in period 3 and 4 compared to period 1 and 2, procedural time was not different among 4 groups. Conclusions: According to the results of this large multicenter study, approximately 40 cases of colorectal ESD should be needed to acquire safe and accurate technique.
692 Endoscopic Resection of Large Laterally Spreading Rectal Adenomas: EMR Versus Esd Hubert H. Nietsch*1,2 1 Div. of Gastroenterology, St. Elisabeth Medical Center, Halle, Germany; 2 Div. of Gastroenterology, Albany Medical College, Albany, NY Aims: Since the advent of screening colonoscopy many more asymptomatic large rectal polyps >5cm in diameter are detected. With the introduction of EMR (endoscopic mucosal resection) and ESD (endoscopic submucosal dissection) we have now endoscopic means to resect those lesions effectively. It is however still unclear whether EMR or ESD is superior in terms of complete resection and safety. Methods: We compare the outcome (perforation, bleeding, complete resection, recurrence rate) in two cohorts of patients with laterally spreading rectal adenomas >5cm who were either treated by EMR or ESD in our center. Results: 62 large laterally spreading rectal adenomas in consecutive patients’ (age 45-84 years) were completely resected endoscopically. ESD en-bloc resection was performed in 23 patients. All other lesions were excised by piecemeal EMR. Prior to resection a careful examination under white light and NBI was performed using the Paris classification. In comparison ESD took about three times as long as EMR (average procedure time 98 min vs 37 min) with comparable intra- and postoperative bleeding rates (5% in each group). No perforations were encountered. All en-bloc ESD specimens were R0 on histology. In one patient deep submucosal invasion of the submucosa (>1000mm) was present. The patient underwent surgical resection 6 weeks after the endoscopy without evidence of remaining tumor or lymph node invasion. The most striking difference in the two groups was seen regarding recurrence of adenomas during 6 months follow-up: 0% in the ESD cohort and 12% in the piecemeal EMR group. All recurrent adenomas after EMR could however be easily resected by snare polypectomy without any further recurrence over the next 12 months. The calculated average equipment cost for ESD (hook knife, dual knife, injectate, transparent cap) was significantly higher compared to EMR (687$ vs. 39$). Conclusion: EMR and ESD are equally effective in resecting large laterally spreading lesions of the rectum despite the higher rate of post-EMR adenoma recurrence which did however not impact the patients overall cure rate after one year. ESD is significantly more time consuming and costly.
693 Cold Piecemeal Endoscopic Mucosal Resection (EMR) for Large Sessile Serrated Colonic Polyps Nicholas J. Tutticci*1,2, David G. Hewett1,2 1 Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia; 2 School of Medicine, University of Queensland, Brisbane, Queensland, Australia Background and Aim: Sessile serrated polyps (SSPs) are important colorectal cancer precursors however the optimal technique for the removal of large lesions remains unknown. Conventional polypectomy has limited efficacy and conventional EMR has a risk of delayed bleeding and perforation. Cold snare resection overcomes these safety concerns, although in practice, piecemeal resection is required for large lesions. In this study, we describe and evaluate a modified cold piecemeal EMR technique for large SSPs. Patients and Methods: Consecutive patients of 2 endoscopists at a single center with one or more 10mm SSPs were included. Patients on anticoagulant/antiplatelet therapy other than aspirin were excluded . Our modified EMR technique comprised: 1) submucosal injection of succinylated gelatin with dilute methylene blue, 2) piecemeal cold snare resection of all visible polyp with a
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