- Email: [email protected]
Case Sensitive Confirmation of Endoscopic Findings in Viral Gastroenteritis
Abstracts
registry. It is believd that the incidence of CA is increasing. CP smaller than 1cm are found commonly during colonoscopy. The significance of biopsying all diminutive polyps is not unknown. Objectives: To analyze the clinical significance of CP smaller than 1cm and their correlation with patient age and pathologic findings in a South America country. MethodThe clinical data of all patients who underwent colonoscopy and polypectomy during the period from August 2006 to December 2007 was reviewed retrospectively. Colonoscopies for all indications were included. Polypectomy was performed using snare and forceps biopsies, with or without electrocoagulation. None of the polyps appeared malignant. The polyps were classified according to size: diminutive- 1-5 mm; small- 6-9,9 mm; large- R1 cm. Polyps with advanced pathology included all polyps with adenocarcinoma, severe dysplasia and tubulovillous adenomas with more than 25% villous component. Results 1249 CP were diagnosed and removed from 852 patients (53% female, mean age 63 years) as shown in table 1. 630 CP (50.5%) were diminutive, 390 (31.22%) were small and 229 (18.3%) large. 195 CP (15.6%) contained advanced pathology: 28 severe dysplasia (2.24%); 11 adenocarcinoma (0.88%); 156 tubulovillous adenomas (12.5%). Importantly, 109 of those CP with advanced pathology were ! 1cm (8.7%). If only CP ! 1 cm were considered (1020), 109 (10.7%) were diagnosed as advanced pathology, 5 (0.5%) of them as adenocarcinoma (4 diminutive polyps and 1 small polyp). Among the polyps with advanced pathologic findings 174 (89.2%) were patientsO50years of age and, 100 (57.4%) polyps !1 cm in size. Conclusion In patients undergoing colonoscopy for all indications in Brazil, colon polyps !1 cm are associated with advanced pathology in 10.7% and, adenocarcinoma in 0.5%. Among patients O 50 years, they represent 57.4% of all CP with advanced pathology in our population. This has implications for guidelines regarding CT colonography in this country.
T1433 Clinicopathological Study of Colorectal Cancer in Patients with Ulcerative Colitis Takafumi Ando, Osamu Watanabe, Kazuhiro Ishiguro, Motofusa Hasegawa, Nobuyuki Miyake, Shinya Kondo, Tsuyoshi Kato, Ryoji Miyahara, Naoki Ohmiya, Yasumasa Niwa, Hidemi Goto Aim: Colorectal cancer (CRC) was first recognized as a complication of ulcerative colitis (UC) in 1925, and the increased risk has since been confirmed in a multitude of epidemiological studies. To our knowledge, all of these studies have been conducted in Western countries, however. The aim of this study was to identify the clinicopathological features of ulcerative colitis-related CRC in a consecutive series of patients at a single hospital in central Japan. Methods: 309 (170 males, 139 females, mean age 30) consecutive patients diagnosed with ulcerative colitis were invited to enroll and investigated for the development of CRC. 240 patients had relapsing-remitting disease, 54 had chronic continuous disease, 16 had experienced one attack only, 2 had the acute fulminating type, and 2 were unknown. With regard to disease extension, 181 cases were of the pan-colitis type, 84 were left-sided colitis, and 42 were proctitis. Two patients (1%) had a family history of colorectal cancer and 45 (14%) were past or current smokers. Results: Colorectal cancer developed in seven patients (male to female ratio of 1: 6), which was 2.2% of the total. Average age at the onset of ulcerative colitis was 28 years. Average age at onset of cancer was 44 years, with an average disease duration at the time of cancer onset of 192 months. Ulcerative colitis was of the pancolitis type in all cases. Three patients (43%) showed the relapse-remitting type and four (57%) the chronic continuing type. Three patients (43%) had a family history of cancer, in particular colorectal cancer in one patient (14%). None of the patients had a history of smoking. The histological type of cancer was well differentiated tubular adenocarcinoma and poorly differentiated adenocarcinoma in three patients (43%) each, and endocrine cell carcinoma in one (14%). Conclusion: Development of colorectal cancer is more likely to occur in patients with ulcerative colitis that is long-standing, and that is more extensive than left-sided colitis, particularly in those with a family history of colorectal cancer, inflammatory polyps, or dysplasia. CRCs which occurred in our patients with UC were often poorly differentiated and had a poor prognosis.
demographic data, details of the DBE procedure - type of sedation or anesthesia, indication for the procedure, cecal intubation, procedure time, findings, therapy, and outcome were recorded in the database. Results: A single endoscopist performed DBE after a prior failed colonoscopy on 22 consecutive patients. Demographics: Mean age: 65.3 9.678 yrs; Female predominance (68%); Mean BMI: 30.05 8.32. Causes of failed colonoscopy: Tortuous & redundant colon: 20 (7 patients had adhesions) & Fixed colon from adhesions: 2. Cecal Intubation by DBE: 20/22 (91%); 2/22 had failed DBE from fixed sigmoid colon from dense adhesions (confirmed by laparoscopy). Cecal Intubation Time: 22.78 11.5 minutes. Total procedure time: 59.9 27.9 minutes. DBE cecal insertion time was shorter than total procedure time with a PC (majority of the time was spent for intubation): 22.78 11.5 vs. 36.63 16.24, pZ 0.003. Findings and Therapy: 17 additional polyps were found on DBE exam, including three patients with flat lesions in the cecum that required laparoscopic resection (nZ1), laparoscopic assisted endoscopic mucosal resection (nZ1), and endoscopic mucosal resection through DBE (nZ1). Complications: nil. Conclusion: DBE is technically successful in patients with failed cecal intubation with colonoscope. It allows detection and managemen of flat lesions that could be missed by barium enema or CT colography.
T1435 Cap-Assisted Mucosectomy (EMR-C) Is Safe and Effective for the Removal of Flat Colorectal Polyps (FCP) Simon K. Lo, Michael Schafer Introduction: Free-hand snare mucosectomy is currently the preferred ablative method for slightly raised colonic adenomas, but it is technically difficult and has a high incidence of residual lesions and bleeding. EMR-C has been described as risky. Data on EMR-C for FCP are limited. Aim: Evaluate the safety and efficacy of EMR-C in removing FCP. Methods: Retrospective review of all flat (defined as entirely or mostly flat) polyps referred for endoscopic ablation from 1/2007-11/ 2008. Results: 50 patients with FCP were referred and EMR was attempted in 49 sessions (including 2 F/U EMR for incomplete removal). Lesion types: Tubular adenoma-21, tubulovillous-17, serrated adenoma-5, hyperplastic polyp-3, tubulovillous adenoma with cancer-2, inflammatory polyp-1, villous adenoma-1. Avg lesion size: 2.5cmX1.9cm. Most FCPs were located in the right colon (Cecum-8, AC14, HF-4, TC-12, SF-1, DC-6, Sig-1, Rectum-4). 41 (80%) procedures led to total ablation in a single session. Clips were used in 14 (29%) procedures (Reasons: prophylaxis-10, perforation-2, intra-procedure bleeding-2). Primary EMR method used: Olympus EMR-C-40 (82%), Duette EMR-C-3, Free-hand-6. Supplemental ablative technique: Cautery-5 (APC/coag-forceps), free-hand polypectomy-1. Postprocedure complications happened in 14% of cases. These 7 complications required 14 hospital days. There was no post-procedure bleeding. One patient with a clip-closed perforation underwent surgical resection and was found to have a focal cancer. Conclusions: Careful initial endoscopic case selection can identify flat lesions for complete ablation in 1 session in most cases. Self-limited complications are common and are the reason for specialized EMR training. Our primarily EMR-C technique of FCP removal has resulted in no post-procedure bleeding. Contrary to common concerns, Olympus EMR-C is safe and highly effective in ablating these colonic lesions and may be considered the primary mode of therapy.
Reason for failed single procedure Primary non-lifting IC valve involvement Poor bowel prep Lesion too large Technical difficulty Partial non-lifting
Complications
T1434 Technical Success and Outcome of Double Balloon Endoscopy After Failed Cecal Intubation with a Colonoscope Rajeswari Anaparthy, Sashidhar Sagi, Gottumukkala S. Raju Background: The U.S. Multisociety Task Force recommended cecal intubation rate of 95% in patients undergoing screening colonoscopy. Maximizing cecal intubation rate results in positive outcomes, while failure to reach the cecum incurs cost, risks, and inconvenience of barium enema that may miss lesions. A number of different endoscopes or techniques could be used to reach the cecum in patients with prior failed colonoscopy. Recently, double balloon endoscopy (DBE) has been shown to be useful in reaching deep into the small intestine from the antegrade and the retrograde route. After going through training on an ex-vivo porcine small bowel, we started using DBE in patients with failed cecal intubation with a pediatric colonoscope (PC). Aim: We report the technical success and outcome of patients who had undergone DBE after a failed cecal intubation with a PC. Methods: This is a retrospective study of data collected in the endoscopic database. Patient
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Post-polypectomy syndrome Volvulus (spontaneous decompression) Urinary retention Clip-closed perforation Exacerbation of chronic abdominal pain Intense focal abdominal pain
EMR attempted No No No Yes Yes Yes
Number of patients 3 1 1 1 1 2
Number of patients 1 1 1 2 1 1
T1436 Case Sensitive Confirmation of Endoscopic Findings in Viral Gastroenteritis Akihiro Nishizawa, Hitoshi Nakajima, Masaki Sanaka, Naoto Egawa, Yoshihisa Urita, Motonobu Sugimoto Background/Aim: An increasing awareness of the etiology of sporadic and outbreak cases of viral gastroenteritis has transformed the traditional dichotomous view that, Norovirus causes epidemic viral gastroenteritis in older children and adults
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB295
Abstracts
whereas Rotavirus causes diarrhea in infants and young children. We previously reported that 14.3% of adult diarrhea was caused by group A Rotavirus infection (Lancet, 357, 9272, 2001). Thereafter other viruses such as Astrovirus, Adenovirus, Norovirus, and Enterovirus have turned out to be also responsible for gastroenteritis and endoscopic examination has increased gradually. We already presented preliminary data referring to Rotavirus infection in ischemic colitis (GIE vol. 55. No.5. AB265, 2002). We aim to study the general endoscopic aspect of viral gastroenteritis in this paper under the hypothesis the other viruses also might be linked to mucosal changes. !bSubjects/Method] We performed colonoscopy prospectively in consecutive 113 patients (M/F; 44/69, mean age; 55) out of 524 acute sporadic diarrhea (including bloody diarrhea) in adult, during the six years from 2001-2006. Referring to virus, Astrovirus, Adenovirus, Norovirus, and Enterovirus were examined by RT-PCR method and Rotavirus by ELISA, and enteric pathogenic bacteria was examined by conventional stool culture. This endoscopic examination was carried out without any preparation to avoid its influence on mucosal findings and to assist further examination of enteric pathogens. We could have a chance to get supplemental stool sample at the endoscopy because we cleansed endoscopes according to the standard precaution. [Result] Enteric viruses were detected in 36 out of 113 patients (32%). Detected viruses are 19 Rotavirus, 13 Astrovirus, 6 Adenovirus, and 5 Norovirus (including duplication). Bacteria were detected in 16(14%), and no pathogens were in 56(50%). Endoscopic diagnoses were ischemic colitis pattern (66.7%), non-specific colitis pattern (22.2%), ulcerative colitis pattern (diffuse inflammation) (2.8%), normal (2.8%), and others (5.6%). Finding of ischemic colitis pattern is especially dominant in Astrovirus (100.0%) and Rotavirus (53.8%) cases. [Conclusion] 1. Viral infection as a single infection was confirmed at the rate of 32% (36/113) in sporadic acute gastroenteritis. 2. Endoscopy revealed that colitis happened in the 66.7% (24/36) of viral gastroenteritis.3. Ischemic colitis pattern inflammation was dominant among acute viral gastroenteritis. We speculate, as a pathogenesis, acute increase of intrinsic pressure by diarrhea induced by virus more than their own toxin itself.
T1437 Depressed Colorectal Neoplasias in a Reference Center in Brazil Lix A. Reis De Oliveira, Paula Uejo, Rosangela Deliza Introduction: The depressed colorectal neoplasias have received increasing attention because they might be an initial stage of colorectal cancer and they are expected to have a poor outcome because of the high rates of submucosa invasion and the more aggressive biological behavior comparing with the polypoid lesions. Objectives: The aim of this study was to review the prevalence of depressed colorectal neoplasias diagnosed at our institution and the pathologic findings of these lesions. Patients and Methods: The data was collected retrospectively from colonic lesions resected at the Center of Advanced Endoscopy, in Campinas, Brazil, from January 2006 to July 2008. We detected 4251 colorectal lesions in 3886 patients. Forty seven lesions were endoscopically recognized as depressed colorectal tumors and were examined by endoscopic and clinicopathologic features. The lesions were from 41 patients (19 men and 22 women), with a median age of 64.9 years (range: 42 to 87 years). The lesions were carefully visualized by the usual method of observation and by the indigo carmine dye spraying method to confirm that they had a depressed area and than they were magnified. Result: The depressed colorectal neoplasias represented 1.1% of all colonic lesions diagnosed in our institution. The mean diameter of the lesions was 3.86mm (range: 02 to 15mm). All these lesions had a depressed morphology, types IIc, IIa þ IIc or IIc þ IIa, and all of them had in the depressed area a IIIs pit pattern, according to Kudo’s classification. Lesions were histopathologically classified into two types according Vienna’s classification: Group 3 (nZ43), and Group 4 (nZ4). The locations of the lesions had equal distribution in the right and left colon. The four early cancers were confined to the mucosa. Endoscopic treatment was performed in all the lesions, 10 by snare polypectomy and the other 37 by endoscopic mucosal resection (EMR). The complications were minor bleeding that was controlled by endoscopic methods. There was no major complication as perforation. Conclusion: Despite the low incidence and the difficult diagnosis of this type of lesion, they must be diagnosed and treated, because according to literature data, they have a high malignant potential and show a high percentage of submucosal invasion. In this series we didn’t have submucosal invasion probably because most lesions analyzed had a small diameter (90% until 5mm). Careful examination with greater times to withdraw and the knowledge of this type of lesion probably will improve the quality of colonoscopy and perhaps decrease the incidence of interval’s cancer.
T1438 Effectiveness of High Dose Barium Enema Filling for Colonic Diverticular Bleeding AI Fujimoto, Yoshinori Igarashi, Yasukiyo Sumino Background: High dose barium impaction therapy has been known to be effective as hemostasis for colonic diverticular bleeding. However, there are few reports on long-term therapeutic effects. Objective: In the present study, the recurrence rate of colonic diverticular bleeding in high dose barium filling was compared to that of endoscopic hemostasis. Materials and Methods: Study subjects were consecutive 57 cases of colonic diverticular bleeding in which conservative treatment failed to stop
AB296 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
bleeding within 12 hrs after hospital admission during the period between 2003 and 2008. Lower gastrointestinal endoscopy was performed immediately after admission. Cases with identifiable or presumptive sources of bleeding received on the spot endoscopic hemostasis. Cases with undetectable sources of bleeding received high dose barium impaction therapy. The 57 patients were divided into 3 groups; 37 in the solely endoscopic hemostasis group, 11 in the solely high dose barium impaction group and 9 in the endoscopic hemostasis þ additional palliative high dose barium impaction group. The duration of observation was between 1 and 56 months (mean 12.7 months). Results: The rates of recurrence of bleeding were 18/37 (48.6%) in the solely endoscopic hemostasis group, 6/11 (54.5%) in the solely high dose barium impaction group and 2/9 (22.2%) in the endoscopic hemostasis þ additional palliative high dose barium impaction group. Although in the KaplanMeier test, there was no significant difference among the 3 groups (pZ0.3930), the endoscopic hemostasis þ additional palliative high dose barium impaction group had a somewhat lower recurrence than the other 2 groups. Conclusion: Colonic diverticular bleeding should be examined with lower gastrointestinal endoscopy at the early stage of bleeding. It is recommended to treat cases with identifiable sources of bleeding with endoscopic hemostasis. For cases with undetectable sources of bleeding, high dose barium impaction seems to be as effective as endoscopic hemostasis for prevention of recurrence of bleeding.
T1439 Flushknife Versus Flexknife for Colorectal Endoscopic Submucosal Dissection: A Progress Report of a Randomized Phase II Trial (FF Study) Yoji Takeuchi, Noriya Uedo, Hiroyasu Iishi, Ryu Ishihara Background: Endoscopic submucosal dissection (ESD) for superficial gastric and esophageal neoplasm has been widely spread in Japan. But ESD for colorectal neoplasms has not been a common procedure because of its technical difficulty. Flexknife has been used mainly for colorectal ESD and large number case series were reported previously. On the other hand, Flushknife which is a newly developed endoknife combined with a water jet function is expected to reduce the difficulty of colorectal ESD. Objective: To investigate the superiority of Fllushknife to Flexknife for colorectal ESD. Design: A prospective randomized controlled open trial. Setting: A single referral cancer center. Patients: We consider patients eligible if they have superficial colorectal epitherial neoplasm larger than 20 mm in diameter and no evidence of submucosal or deeper invasion. Sample size was calculated based on the preliminary results of colorectal ESD using each endoknife. More than 25 lesions are needed to enroll in each group. Intervention: Lesions are randomly assigned to Flexknife group (lesions undergone colorectal ESD using Flexknife mainly) or Flushknife group (using Flushknife mainly). Main Outcome measurements: A procedure time. Interim results: From April 2008 to November 2008, 27 lesions have been enrolled in this study. No fatal or major adverse events have occurred. We experienced one perforation case fixed using endoclips during procedure and emergency surgery was not needed. Limitation: Small sample size in a single center. Conclusion: An interim analysis has not been scheduled and we can’t know the differences between two groups as yet. This study is progressing satisfactorily with tolerable adverse event incidence. Colorectal ESD is technically difficult but efforts to standardize the procedure will be help for spread.
T1440 Limited Long-Term Clinical Success of Self-Expanding Metal Stents in Patients with Obstructive Colorectal Cancer Gloria Fernandez-Esparrach, Josep M. Bordas, Maria Dolores Giraldez, Miguel Camacho, Leonel Zavala, Angels Gines, Maria Pellise, Oriol Sendino, Andres Cardenas, Antoni Castells, Josep Llach Background: Self-expanding metal stents (SEMS) are being increasingly used to solve malignant colorectal obstruction. However, complications have been reported in up to 50% of patients. There is few information on long-term outcomes in these patients. Aim: To retrospectively assess the long-term clinical success of SEMS in patients with a malignant colorectal obstruction in a single tertiary center and to identify possible prognostic factors of complications. Patients and Methods: a total of 47 attempts to insert colorectal SEMS were made in 47 patients during a five-year period. 9-cm stents were placed under endoscopic and radiologic monitoring. After 24 hours, all the patients underwent abdominal x-ray to verify correct positioning of the stent. Patients were followed at the outpatient clinic. Results: insertion success was achieved in 45 (96%) and acceptable initial colonic decompression in 43 of 47 (91%) attempts and in 43 of 45 (96%) of successfully inserted stents. Stents were placed in the rectum (7, 15%), sigmoid (33, 70%), left colon (4, 9%) and anastomotic recurrence (3, 6%). The majority of patients had a IV-stage disease (40, 85%). SEMS served as a bridge to scheduled surgery in 10 of 47 (21%) patients and as a palliative definitive treatment in 33 of 47 (70%). Longterm clinical failure occurred in 22 (47%) patients and was due to complications: perforation (4, 8%), obstruction (10, 21%), migration (7, 15%), and tenesmus (1, 2%). Perforations occurred during insertion (nZ1) and at 3, 4 and 34 days postinsertion, and all patients died. The cumulative mortality rate was 25% (12 cases) at a median follow-up of 3 months. In the ‘‘bridge to surgery’’ group, primary
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registry. It is believd that the incidence of CA is increasing. CP smaller than 1cm are found commonly during colonoscopy. The significance of biopsying all diminutive polyps is not unknown. Objectives: To analyze the clinical significance of CP smaller than 1cm and their correlation with patient age and pathologic findings in a South America country. MethodThe clinical data of all patients who underwent colonoscopy and polypectomy during the period from August 2006 to December 2007 was reviewed retrospectively. Colonoscopies for all indications were included. Polypectomy was performed using snare and forceps biopsies, with or without electrocoagulation. None of the polyps appeared malignant. The polyps were classified according to size: diminutive- 1-5 mm; small- 6-9,9 mm; large- R1 cm. Polyps with advanced pathology included all polyps with adenocarcinoma, severe dysplasia and tubulovillous adenomas with more than 25% villous component. Results 1249 CP were diagnosed and removed from 852 patients (53% female, mean age 63 years) as shown in table 1. 630 CP (50.5%) were diminutive, 390 (31.22%) were small and 229 (18.3%) large. 195 CP (15.6%) contained advanced pathology: 28 severe dysplasia (2.24%); 11 adenocarcinoma (0.88%); 156 tubulovillous adenomas (12.5%). Importantly, 109 of those CP with advanced pathology were ! 1cm (8.7%). If only CP ! 1 cm were considered (1020), 109 (10.7%) were diagnosed as advanced pathology, 5 (0.5%) of them as adenocarcinoma (4 diminutive polyps and 1 small polyp). Among the polyps with advanced pathologic findings 174 (89.2%) were patientsO50years of age and, 100 (57.4%) polyps !1 cm in size. Conclusion In patients undergoing colonoscopy for all indications in Brazil, colon polyps !1 cm are associated with advanced pathology in 10.7% and, adenocarcinoma in 0.5%. Among patients O 50 years, they represent 57.4% of all CP with advanced pathology in our population. This has implications for guidelines regarding CT colonography in this country.
T1433 Clinicopathological Study of Colorectal Cancer in Patients with Ulcerative Colitis Takafumi Ando, Osamu Watanabe, Kazuhiro Ishiguro, Motofusa Hasegawa, Nobuyuki Miyake, Shinya Kondo, Tsuyoshi Kato, Ryoji Miyahara, Naoki Ohmiya, Yasumasa Niwa, Hidemi Goto Aim: Colorectal cancer (CRC) was first recognized as a complication of ulcerative colitis (UC) in 1925, and the increased risk has since been confirmed in a multitude of epidemiological studies. To our knowledge, all of these studies have been conducted in Western countries, however. The aim of this study was to identify the clinicopathological features of ulcerative colitis-related CRC in a consecutive series of patients at a single hospital in central Japan. Methods: 309 (170 males, 139 females, mean age 30) consecutive patients diagnosed with ulcerative colitis were invited to enroll and investigated for the development of CRC. 240 patients had relapsing-remitting disease, 54 had chronic continuous disease, 16 had experienced one attack only, 2 had the acute fulminating type, and 2 were unknown. With regard to disease extension, 181 cases were of the pan-colitis type, 84 were left-sided colitis, and 42 were proctitis. Two patients (1%) had a family history of colorectal cancer and 45 (14%) were past or current smokers. Results: Colorectal cancer developed in seven patients (male to female ratio of 1: 6), which was 2.2% of the total. Average age at the onset of ulcerative colitis was 28 years. Average age at onset of cancer was 44 years, with an average disease duration at the time of cancer onset of 192 months. Ulcerative colitis was of the pancolitis type in all cases. Three patients (43%) showed the relapse-remitting type and four (57%) the chronic continuing type. Three patients (43%) had a family history of cancer, in particular colorectal cancer in one patient (14%). None of the patients had a history of smoking. The histological type of cancer was well differentiated tubular adenocarcinoma and poorly differentiated adenocarcinoma in three patients (43%) each, and endocrine cell carcinoma in one (14%). Conclusion: Development of colorectal cancer is more likely to occur in patients with ulcerative colitis that is long-standing, and that is more extensive than left-sided colitis, particularly in those with a family history of colorectal cancer, inflammatory polyps, or dysplasia. CRCs which occurred in our patients with UC were often poorly differentiated and had a poor prognosis.
demographic data, details of the DBE procedure - type of sedation or anesthesia, indication for the procedure, cecal intubation, procedure time, findings, therapy, and outcome were recorded in the database. Results: A single endoscopist performed DBE after a prior failed colonoscopy on 22 consecutive patients. Demographics: Mean age: 65.3 9.678 yrs; Female predominance (68%); Mean BMI: 30.05 8.32. Causes of failed colonoscopy: Tortuous & redundant colon: 20 (7 patients had adhesions) & Fixed colon from adhesions: 2. Cecal Intubation by DBE: 20/22 (91%); 2/22 had failed DBE from fixed sigmoid colon from dense adhesions (confirmed by laparoscopy). Cecal Intubation Time: 22.78 11.5 minutes. Total procedure time: 59.9 27.9 minutes. DBE cecal insertion time was shorter than total procedure time with a PC (majority of the time was spent for intubation): 22.78 11.5 vs. 36.63 16.24, pZ 0.003. Findings and Therapy: 17 additional polyps were found on DBE exam, including three patients with flat lesions in the cecum that required laparoscopic resection (nZ1), laparoscopic assisted endoscopic mucosal resection (nZ1), and endoscopic mucosal resection through DBE (nZ1). Complications: nil. Conclusion: DBE is technically successful in patients with failed cecal intubation with colonoscope. It allows detection and managemen of flat lesions that could be missed by barium enema or CT colography.
T1435 Cap-Assisted Mucosectomy (EMR-C) Is Safe and Effective for the Removal of Flat Colorectal Polyps (FCP) Simon K. Lo, Michael Schafer Introduction: Free-hand snare mucosectomy is currently the preferred ablative method for slightly raised colonic adenomas, but it is technically difficult and has a high incidence of residual lesions and bleeding. EMR-C has been described as risky. Data on EMR-C for FCP are limited. Aim: Evaluate the safety and efficacy of EMR-C in removing FCP. Methods: Retrospective review of all flat (defined as entirely or mostly flat) polyps referred for endoscopic ablation from 1/2007-11/ 2008. Results: 50 patients with FCP were referred and EMR was attempted in 49 sessions (including 2 F/U EMR for incomplete removal). Lesion types: Tubular adenoma-21, tubulovillous-17, serrated adenoma-5, hyperplastic polyp-3, tubulovillous adenoma with cancer-2, inflammatory polyp-1, villous adenoma-1. Avg lesion size: 2.5cmX1.9cm. Most FCPs were located in the right colon (Cecum-8, AC14, HF-4, TC-12, SF-1, DC-6, Sig-1, Rectum-4). 41 (80%) procedures led to total ablation in a single session. Clips were used in 14 (29%) procedures (Reasons: prophylaxis-10, perforation-2, intra-procedure bleeding-2). Primary EMR method used: Olympus EMR-C-40 (82%), Duette EMR-C-3, Free-hand-6. Supplemental ablative technique: Cautery-5 (APC/coag-forceps), free-hand polypectomy-1. Postprocedure complications happened in 14% of cases. These 7 complications required 14 hospital days. There was no post-procedure bleeding. One patient with a clip-closed perforation underwent surgical resection and was found to have a focal cancer. Conclusions: Careful initial endoscopic case selection can identify flat lesions for complete ablation in 1 session in most cases. Self-limited complications are common and are the reason for specialized EMR training. Our primarily EMR-C technique of FCP removal has resulted in no post-procedure bleeding. Contrary to common concerns, Olympus EMR-C is safe and highly effective in ablating these colonic lesions and may be considered the primary mode of therapy.
Reason for failed single procedure Primary non-lifting IC valve involvement Poor bowel prep Lesion too large Technical difficulty Partial non-lifting
Complications
T1434 Technical Success and Outcome of Double Balloon Endoscopy After Failed Cecal Intubation with a Colonoscope Rajeswari Anaparthy, Sashidhar Sagi, Gottumukkala S. Raju Background: The U.S. Multisociety Task Force recommended cecal intubation rate of 95% in patients undergoing screening colonoscopy. Maximizing cecal intubation rate results in positive outcomes, while failure to reach the cecum incurs cost, risks, and inconvenience of barium enema that may miss lesions. A number of different endoscopes or techniques could be used to reach the cecum in patients with prior failed colonoscopy. Recently, double balloon endoscopy (DBE) has been shown to be useful in reaching deep into the small intestine from the antegrade and the retrograde route. After going through training on an ex-vivo porcine small bowel, we started using DBE in patients with failed cecal intubation with a pediatric colonoscope (PC). Aim: We report the technical success and outcome of patients who had undergone DBE after a failed cecal intubation with a PC. Methods: This is a retrospective study of data collected in the endoscopic database. Patient
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Post-polypectomy syndrome Volvulus (spontaneous decompression) Urinary retention Clip-closed perforation Exacerbation of chronic abdominal pain Intense focal abdominal pain
EMR attempted No No No Yes Yes Yes
Number of patients 3 1 1 1 1 2
Number of patients 1 1 1 2 1 1
T1436 Case Sensitive Confirmation of Endoscopic Findings in Viral Gastroenteritis Akihiro Nishizawa, Hitoshi Nakajima, Masaki Sanaka, Naoto Egawa, Yoshihisa Urita, Motonobu Sugimoto Background/Aim: An increasing awareness of the etiology of sporadic and outbreak cases of viral gastroenteritis has transformed the traditional dichotomous view that, Norovirus causes epidemic viral gastroenteritis in older children and adults
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB295
Abstracts
whereas Rotavirus causes diarrhea in infants and young children. We previously reported that 14.3% of adult diarrhea was caused by group A Rotavirus infection (Lancet, 357, 9272, 2001). Thereafter other viruses such as Astrovirus, Adenovirus, Norovirus, and Enterovirus have turned out to be also responsible for gastroenteritis and endoscopic examination has increased gradually. We already presented preliminary data referring to Rotavirus infection in ischemic colitis (GIE vol. 55. No.5. AB265, 2002). We aim to study the general endoscopic aspect of viral gastroenteritis in this paper under the hypothesis the other viruses also might be linked to mucosal changes. !bSubjects/Method] We performed colonoscopy prospectively in consecutive 113 patients (M/F; 44/69, mean age; 55) out of 524 acute sporadic diarrhea (including bloody diarrhea) in adult, during the six years from 2001-2006. Referring to virus, Astrovirus, Adenovirus, Norovirus, and Enterovirus were examined by RT-PCR method and Rotavirus by ELISA, and enteric pathogenic bacteria was examined by conventional stool culture. This endoscopic examination was carried out without any preparation to avoid its influence on mucosal findings and to assist further examination of enteric pathogens. We could have a chance to get supplemental stool sample at the endoscopy because we cleansed endoscopes according to the standard precaution. [Result] Enteric viruses were detected in 36 out of 113 patients (32%). Detected viruses are 19 Rotavirus, 13 Astrovirus, 6 Adenovirus, and 5 Norovirus (including duplication). Bacteria were detected in 16(14%), and no pathogens were in 56(50%). Endoscopic diagnoses were ischemic colitis pattern (66.7%), non-specific colitis pattern (22.2%), ulcerative colitis pattern (diffuse inflammation) (2.8%), normal (2.8%), and others (5.6%). Finding of ischemic colitis pattern is especially dominant in Astrovirus (100.0%) and Rotavirus (53.8%) cases. [Conclusion] 1. Viral infection as a single infection was confirmed at the rate of 32% (36/113) in sporadic acute gastroenteritis. 2. Endoscopy revealed that colitis happened in the 66.7% (24/36) of viral gastroenteritis.3. Ischemic colitis pattern inflammation was dominant among acute viral gastroenteritis. We speculate, as a pathogenesis, acute increase of intrinsic pressure by diarrhea induced by virus more than their own toxin itself.
T1437 Depressed Colorectal Neoplasias in a Reference Center in Brazil Lix A. Reis De Oliveira, Paula Uejo, Rosangela Deliza Introduction: The depressed colorectal neoplasias have received increasing attention because they might be an initial stage of colorectal cancer and they are expected to have a poor outcome because of the high rates of submucosa invasion and the more aggressive biological behavior comparing with the polypoid lesions. Objectives: The aim of this study was to review the prevalence of depressed colorectal neoplasias diagnosed at our institution and the pathologic findings of these lesions. Patients and Methods: The data was collected retrospectively from colonic lesions resected at the Center of Advanced Endoscopy, in Campinas, Brazil, from January 2006 to July 2008. We detected 4251 colorectal lesions in 3886 patients. Forty seven lesions were endoscopically recognized as depressed colorectal tumors and were examined by endoscopic and clinicopathologic features. The lesions were from 41 patients (19 men and 22 women), with a median age of 64.9 years (range: 42 to 87 years). The lesions were carefully visualized by the usual method of observation and by the indigo carmine dye spraying method to confirm that they had a depressed area and than they were magnified. Result: The depressed colorectal neoplasias represented 1.1% of all colonic lesions diagnosed in our institution. The mean diameter of the lesions was 3.86mm (range: 02 to 15mm). All these lesions had a depressed morphology, types IIc, IIa þ IIc or IIc þ IIa, and all of them had in the depressed area a IIIs pit pattern, according to Kudo’s classification. Lesions were histopathologically classified into two types according Vienna’s classification: Group 3 (nZ43), and Group 4 (nZ4). The locations of the lesions had equal distribution in the right and left colon. The four early cancers were confined to the mucosa. Endoscopic treatment was performed in all the lesions, 10 by snare polypectomy and the other 37 by endoscopic mucosal resection (EMR). The complications were minor bleeding that was controlled by endoscopic methods. There was no major complication as perforation. Conclusion: Despite the low incidence and the difficult diagnosis of this type of lesion, they must be diagnosed and treated, because according to literature data, they have a high malignant potential and show a high percentage of submucosal invasion. In this series we didn’t have submucosal invasion probably because most lesions analyzed had a small diameter (90% until 5mm). Careful examination with greater times to withdraw and the knowledge of this type of lesion probably will improve the quality of colonoscopy and perhaps decrease the incidence of interval’s cancer.
T1438 Effectiveness of High Dose Barium Enema Filling for Colonic Diverticular Bleeding AI Fujimoto, Yoshinori Igarashi, Yasukiyo Sumino Background: High dose barium impaction therapy has been known to be effective as hemostasis for colonic diverticular bleeding. However, there are few reports on long-term therapeutic effects. Objective: In the present study, the recurrence rate of colonic diverticular bleeding in high dose barium filling was compared to that of endoscopic hemostasis. Materials and Methods: Study subjects were consecutive 57 cases of colonic diverticular bleeding in which conservative treatment failed to stop
AB296 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
bleeding within 12 hrs after hospital admission during the period between 2003 and 2008. Lower gastrointestinal endoscopy was performed immediately after admission. Cases with identifiable or presumptive sources of bleeding received on the spot endoscopic hemostasis. Cases with undetectable sources of bleeding received high dose barium impaction therapy. The 57 patients were divided into 3 groups; 37 in the solely endoscopic hemostasis group, 11 in the solely high dose barium impaction group and 9 in the endoscopic hemostasis þ additional palliative high dose barium impaction group. The duration of observation was between 1 and 56 months (mean 12.7 months). Results: The rates of recurrence of bleeding were 18/37 (48.6%) in the solely endoscopic hemostasis group, 6/11 (54.5%) in the solely high dose barium impaction group and 2/9 (22.2%) in the endoscopic hemostasis þ additional palliative high dose barium impaction group. Although in the KaplanMeier test, there was no significant difference among the 3 groups (pZ0.3930), the endoscopic hemostasis þ additional palliative high dose barium impaction group had a somewhat lower recurrence than the other 2 groups. Conclusion: Colonic diverticular bleeding should be examined with lower gastrointestinal endoscopy at the early stage of bleeding. It is recommended to treat cases with identifiable sources of bleeding with endoscopic hemostasis. For cases with undetectable sources of bleeding, high dose barium impaction seems to be as effective as endoscopic hemostasis for prevention of recurrence of bleeding.
T1439 Flushknife Versus Flexknife for Colorectal Endoscopic Submucosal Dissection: A Progress Report of a Randomized Phase II Trial (FF Study) Yoji Takeuchi, Noriya Uedo, Hiroyasu Iishi, Ryu Ishihara Background: Endoscopic submucosal dissection (ESD) for superficial gastric and esophageal neoplasm has been widely spread in Japan. But ESD for colorectal neoplasms has not been a common procedure because of its technical difficulty. Flexknife has been used mainly for colorectal ESD and large number case series were reported previously. On the other hand, Flushknife which is a newly developed endoknife combined with a water jet function is expected to reduce the difficulty of colorectal ESD. Objective: To investigate the superiority of Fllushknife to Flexknife for colorectal ESD. Design: A prospective randomized controlled open trial. Setting: A single referral cancer center. Patients: We consider patients eligible if they have superficial colorectal epitherial neoplasm larger than 20 mm in diameter and no evidence of submucosal or deeper invasion. Sample size was calculated based on the preliminary results of colorectal ESD using each endoknife. More than 25 lesions are needed to enroll in each group. Intervention: Lesions are randomly assigned to Flexknife group (lesions undergone colorectal ESD using Flexknife mainly) or Flushknife group (using Flushknife mainly). Main Outcome measurements: A procedure time. Interim results: From April 2008 to November 2008, 27 lesions have been enrolled in this study. No fatal or major adverse events have occurred. We experienced one perforation case fixed using endoclips during procedure and emergency surgery was not needed. Limitation: Small sample size in a single center. Conclusion: An interim analysis has not been scheduled and we can’t know the differences between two groups as yet. This study is progressing satisfactorily with tolerable adverse event incidence. Colorectal ESD is technically difficult but efforts to standardize the procedure will be help for spread.
T1440 Limited Long-Term Clinical Success of Self-Expanding Metal Stents in Patients with Obstructive Colorectal Cancer Gloria Fernandez-Esparrach, Josep M. Bordas, Maria Dolores Giraldez, Miguel Camacho, Leonel Zavala, Angels Gines, Maria Pellise, Oriol Sendino, Andres Cardenas, Antoni Castells, Josep Llach Background: Self-expanding metal stents (SEMS) are being increasingly used to solve malignant colorectal obstruction. However, complications have been reported in up to 50% of patients. There is few information on long-term outcomes in these patients. Aim: To retrospectively assess the long-term clinical success of SEMS in patients with a malignant colorectal obstruction in a single tertiary center and to identify possible prognostic factors of complications. Patients and Methods: a total of 47 attempts to insert colorectal SEMS were made in 47 patients during a five-year period. 9-cm stents were placed under endoscopic and radiologic monitoring. After 24 hours, all the patients underwent abdominal x-ray to verify correct positioning of the stent. Patients were followed at the outpatient clinic. Results: insertion success was achieved in 45 (96%) and acceptable initial colonic decompression in 43 of 47 (91%) attempts and in 43 of 45 (96%) of successfully inserted stents. Stents were placed in the rectum (7, 15%), sigmoid (33, 70%), left colon (4, 9%) and anastomotic recurrence (3, 6%). The majority of patients had a IV-stage disease (40, 85%). SEMS served as a bridge to scheduled surgery in 10 of 47 (21%) patients and as a palliative definitive treatment in 33 of 47 (70%). Longterm clinical failure occurred in 22 (47%) patients and was due to complications: perforation (4, 8%), obstruction (10, 21%), migration (7, 15%), and tenesmus (1, 2%). Perforations occurred during insertion (nZ1) and at 3, 4 and 34 days postinsertion, and all patients died. The cumulative mortality rate was 25% (12 cases) at a median follow-up of 3 months. In the ‘‘bridge to surgery’’ group, primary
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