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Colorectal Cancer - How Many Biopsies?
Abstracts Table 1. Accuracy Before Training Correct
Incorrect
Accuracy (%)
35
70.8
Incorrect 44
Accuracy (%) 63.3
85
Table 2. Accuracy After Training Correct 76
W1538 Polyp Detection Rates Do Increase with the Use of High Definition, Wide-Angle Colonoscopes Adam C. Randolph, Tony Merrill, Richard Gerkin, Francisco C. Ramirez, Nooman Gilani Background: Quality assurance is area of endoscopy with ever increasing interest. Ehanced quality in colonoscopy can occur through improvement in technique and through improved technology. The new generation colonoscopes have high definition and a wider viewing angle. However, there is a paucity of data about how these advances add to a higher quality exams. Aim: The aim of this study is to compare the polyp detection rates between the newer H180 series and the 160 series colonoscopes. Methods: Consecutive screening exams were reviewed starting July 2007 until 100 exams with a 180 series Olympus colonoscope and 100 exams with a 160 series colonoscope were encountered. Demographic information including age, sex, and presence of diabetes mellitus was recorded. Number of polyps, number of adenomas, presence of advanced neoplasia, total exam time, time to cecum, quality of preparation and fellow involvement was recorded. A Mann-Whitney U test was used to examine continuous variables and Chi square was used to analyze categorical data, and linear regression was used to predict outcomes. Results: Of the total sample, 95.2% were men and 21.6% were diabetic. Fellows were involved in 27.4% of cases. The average age of the patients in the 180 series scope group was 61.4 and in the 160 series scope group was 61.0 (NS). There was no difference in sex, DM, prep quality, or fellow involvement between groups. Primary results are listed in table 1. Cecal time was predicted by both the involvement of a fellow (p ! 0.001) and endoscope used (p Z 0.028). Involvement of a fellow added 3.17 minutes to the cecal time. Using a 180 series scope added 1.31 minutes to the cecal time. Five factors were predictive of exam time: Cecal time (p ! 0.001), presence of advanced neoplasia (p Z 0.001), number of polyps (p ! 0.001), fellow involvement (p ! 0.001), and quality of preparation (p Z 0.001). Most notably, each polyp found added 1.73 minutes to the exam, fellow involvement added 2.55 minutes, and finding advanced neoplasia added 6.35 minutes to the exam. Conclusions: Screening colonoscopy done with a 180 series Olympus colonoscope was associated with a higher number of polyps found, higher number of adenomas found, and longer exam times. The wide angle and high definition associated with these scopes does seem to lead to detection of more pathology and a higher quality exam. Results: Table 1. No. Polyps (p Z 0.004) No. adenomas (p Z 0.002) Exam time, minutes (p ! 0.001) Time to cecum, minutes (NS)
180 Scope 1.86 0.99 22.8 7.1
160 Scope 1.14 0.62 19.6 6.0
All results expressed in means
W1539 Wide-Angle Colonoscopy Significantly Improves Polyp Detection Rate J. Haringsma, Lieke Hol, M.E. Leerdam Van, E.J. Kuipers Colorectal cancer (CRC) is within the EU the most common malignancy and the 2nd cause of cancer-related death. Screening and surveillance may considerably reduce the risk of CRC, in particular when performed with endoscopy. However, even with appropriate withdrawal times, small adenomas are routinely missed during colonoscopy at a considerable rate. This significantly impairs the efficacy of endoscopic CRC screening in a general population setting (Loeve F, Int J Cancer 2004). Different techniques have been tried to improve adenoma detection, including autofluorescence and chromoendoscopy. The use of wide-angle colonoscopies may also increase adenoma detection. In this prospective randomized study, the impact of wide-angle colonoscopy (WA) on adenoma detection was compared with standard colonoscopy (SC). Methods: Patients seen for colonoscopy CRC screening as part of a population program were randomly assigned to undergo endoscopy with either a 170 degree wide-angle CF Q180L or a 140 degree standard CF Q160L (Olympus Optical, Hamburg, Germany). Withdrawal times and polyp detection rates were noted, and pictures and histology were taken from any suspicious lesion.
AB310 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
Endoscopists were aware of the setting of the detection recording, but not of the comparison between WA and SC. Results: In a total of 186 colonoscopies in patients aged 50 -75 yrs, performed by 6 experienced endoscopists, 650 polyps were detected and retrieved for histological assessment. The groups, WA (n Z 103) and SC (n Z 82) did not differ in demographics, cecal intubation rate (99%) and endoscopists. The mean number of polyps detected with WA was significantly large than SC, 3.99 (range 0-26) versus 2.88 (range 0-20) (p ! 0.001). Also with WA a higher number of adenomas was detected (mean 1.8 vs 1.3; p ! 0.01)Conclusions: 170 degree wideangle colonoscopy significantly increases the adenoma detection rate compared to standard 140 degree colonoscopy. This makes wide-angle colonoscopy considerably more appropriate for endoscopical CRC screening.
W1540 Colorectal Cancer - How Many Biopsies? Benjamin J. Colleypriest, Peter Marden, Amy R. Nicol, Lachlan Ayres, Bhavesh Doshi, John D. Linehan Introduction: Identification and diagnosis of colorectal tumours usually result from biopsies taken at colonoscopy. On occasions when the diagnosis is not clear from the first set of biopsies further sampling may necessitate a repeat colonoscopy with its inherent risks. Currently there are no guidelines recommending the number of biopsies that should be taken on the index colonoscopy. Studies asking the same question in oesophageal1 and combined upper GI cancer2 suggest 6 and 7 biopsies respectively. Aims & Methods: To aim of this study was to suggest the optimal number of biopsies necessary. Data was collected on all colonoscopies with a diagnosis of suspected cancer over a 26 month period. Histological data was collected for initial and repeat biopsies and subsequent surgical specimens. The patients were divided into 2 groups, carcinoma correctly diagnosed at initial biopsy and those needing a second colonoscopy or surgery for diagnosis. Severe dysplasia was counted as a correct diagnosis unless this diagnosis was unsure and a repeat colonoscopy resulted. Results: 217 patients were identified of whom 198 had a histological diagnosis of cancer. Of these 198 patients 182 were correctly diagnosed at index colonoscopy and 16 were diagnosed either on repeat colonoscopy (10) or at surgery (6). 9 patients with suspected cancer not confirmed on initial biopsies neither progressed to surgery nor were re examined endoscopically. 10 patients with suspected cancer were re-examined and diagnosed with non-malignant disease. The number of biopsies in the 16 patients with cancer ‘missed’ at index colonoscopy were statistically lower when compared with the correct group (5.729 0.1392 c/w 4.250 0.4031 p Z 0.0025). Conclusion: This study demonstrates that the sensitivity of diagnosis of a suspected cancer increases with the number of biopsies. A high degree of statistical significance was noted in the lower number of biopsies taken in the group of patients with an initial missed diagnosis. The combined sensitivity of taking 5 or less biopsies (85%) was significantly lower compared to more than 5 (98%) or 6 (99%). We suggest that at least 6 biopsies should be mandatory as a national auditable standard in the context or suspected cancer. References: 1 Quality and safety indicators for endoscopy (2007/2008) - BSG website2 Localizing Colorectal Cancer by Colonoscopy N. Piscatelli, N. Hyman and TOsler. Arch.Surg. 2005;140:932-935 Sensitivity of cancer diagnosis according to number of biopsies taken Number of Biopsies Sensitivity%
2 80
3 86
4 86
5 88
6 98
7 100
8 94
9-13 100
W1541 Endoscopic Submucosal Dissection Using the Newly Developed Ball-Tip Bipolar Current Needle Knife Is Safe and Effective Technique for Large Colorectal Tumors Yutaka Saito, Haruhisa Suzuki, Tsuyoshi Kikuchi, Takahisa Matsuda, Toshio Uraoka, Masakatsu Fukuzawa Background: We previously reported on the safety and usefulness of the bipolar current needle knife (B-knife) for colorectal endoscopic submucosal dissection (ESD). There remains a slight risk of perforation, however, so we developed a Bknife with a ball-shaped tip at the end of the needle which further reduces the risk of perforation. Objective: The aim of this study was to evaluate the safety and efficacy of ESD using the newly developed ball-tip B-knife compared with using a conventional B-knife. Design and setting: Case series conducted at the National Cancer Center Hospital (NCCH), Tokyo, Japan. Patients: Patients with 300 colorectal LSTs were included in this study between January 2003 and November 2007. Through December 2006, 229 colorectal tumors were treated by ESD using a conventional B-knife while 71 colorectal tumors were treated by ESD using the ball-tip B-knife beginning in January 2007. Interventions: ESD procedures were performed using a B-knife and insulation-tip knife (IT knife). After injection of glycerol and sodium hyaluronate acid into the submucosal (sm) layer, a circumferential incision was made and sm dissection was performed. All lesions were determined to be intramucosal or sm superficial by magnified colonoscopy before treatment. Main outcome measurements: We recorded tumor size, operation time, en-bloc resection rate and complications. Results: A total of 300
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Incorrect
Accuracy (%)
35
70.8
Incorrect 44
Accuracy (%) 63.3
85
Table 2. Accuracy After Training Correct 76
W1538 Polyp Detection Rates Do Increase with the Use of High Definition, Wide-Angle Colonoscopes Adam C. Randolph, Tony Merrill, Richard Gerkin, Francisco C. Ramirez, Nooman Gilani Background: Quality assurance is area of endoscopy with ever increasing interest. Ehanced quality in colonoscopy can occur through improvement in technique and through improved technology. The new generation colonoscopes have high definition and a wider viewing angle. However, there is a paucity of data about how these advances add to a higher quality exams. Aim: The aim of this study is to compare the polyp detection rates between the newer H180 series and the 160 series colonoscopes. Methods: Consecutive screening exams were reviewed starting July 2007 until 100 exams with a 180 series Olympus colonoscope and 100 exams with a 160 series colonoscope were encountered. Demographic information including age, sex, and presence of diabetes mellitus was recorded. Number of polyps, number of adenomas, presence of advanced neoplasia, total exam time, time to cecum, quality of preparation and fellow involvement was recorded. A Mann-Whitney U test was used to examine continuous variables and Chi square was used to analyze categorical data, and linear regression was used to predict outcomes. Results: Of the total sample, 95.2% were men and 21.6% were diabetic. Fellows were involved in 27.4% of cases. The average age of the patients in the 180 series scope group was 61.4 and in the 160 series scope group was 61.0 (NS). There was no difference in sex, DM, prep quality, or fellow involvement between groups. Primary results are listed in table 1. Cecal time was predicted by both the involvement of a fellow (p ! 0.001) and endoscope used (p Z 0.028). Involvement of a fellow added 3.17 minutes to the cecal time. Using a 180 series scope added 1.31 minutes to the cecal time. Five factors were predictive of exam time: Cecal time (p ! 0.001), presence of advanced neoplasia (p Z 0.001), number of polyps (p ! 0.001), fellow involvement (p ! 0.001), and quality of preparation (p Z 0.001). Most notably, each polyp found added 1.73 minutes to the exam, fellow involvement added 2.55 minutes, and finding advanced neoplasia added 6.35 minutes to the exam. Conclusions: Screening colonoscopy done with a 180 series Olympus colonoscope was associated with a higher number of polyps found, higher number of adenomas found, and longer exam times. The wide angle and high definition associated with these scopes does seem to lead to detection of more pathology and a higher quality exam. Results: Table 1. No. Polyps (p Z 0.004) No. adenomas (p Z 0.002) Exam time, minutes (p ! 0.001) Time to cecum, minutes (NS)
180 Scope 1.86 0.99 22.8 7.1
160 Scope 1.14 0.62 19.6 6.0
All results expressed in means
W1539 Wide-Angle Colonoscopy Significantly Improves Polyp Detection Rate J. Haringsma, Lieke Hol, M.E. Leerdam Van, E.J. Kuipers Colorectal cancer (CRC) is within the EU the most common malignancy and the 2nd cause of cancer-related death. Screening and surveillance may considerably reduce the risk of CRC, in particular when performed with endoscopy. However, even with appropriate withdrawal times, small adenomas are routinely missed during colonoscopy at a considerable rate. This significantly impairs the efficacy of endoscopic CRC screening in a general population setting (Loeve F, Int J Cancer 2004). Different techniques have been tried to improve adenoma detection, including autofluorescence and chromoendoscopy. The use of wide-angle colonoscopies may also increase adenoma detection. In this prospective randomized study, the impact of wide-angle colonoscopy (WA) on adenoma detection was compared with standard colonoscopy (SC). Methods: Patients seen for colonoscopy CRC screening as part of a population program were randomly assigned to undergo endoscopy with either a 170 degree wide-angle CF Q180L or a 140 degree standard CF Q160L (Olympus Optical, Hamburg, Germany). Withdrawal times and polyp detection rates were noted, and pictures and histology were taken from any suspicious lesion.
AB310 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
Endoscopists were aware of the setting of the detection recording, but not of the comparison between WA and SC. Results: In a total of 186 colonoscopies in patients aged 50 -75 yrs, performed by 6 experienced endoscopists, 650 polyps were detected and retrieved for histological assessment. The groups, WA (n Z 103) and SC (n Z 82) did not differ in demographics, cecal intubation rate (99%) and endoscopists. The mean number of polyps detected with WA was significantly large than SC, 3.99 (range 0-26) versus 2.88 (range 0-20) (p ! 0.001). Also with WA a higher number of adenomas was detected (mean 1.8 vs 1.3; p ! 0.01)Conclusions: 170 degree wideangle colonoscopy significantly increases the adenoma detection rate compared to standard 140 degree colonoscopy. This makes wide-angle colonoscopy considerably more appropriate for endoscopical CRC screening.
W1540 Colorectal Cancer - How Many Biopsies? Benjamin J. Colleypriest, Peter Marden, Amy R. Nicol, Lachlan Ayres, Bhavesh Doshi, John D. Linehan Introduction: Identification and diagnosis of colorectal tumours usually result from biopsies taken at colonoscopy. On occasions when the diagnosis is not clear from the first set of biopsies further sampling may necessitate a repeat colonoscopy with its inherent risks. Currently there are no guidelines recommending the number of biopsies that should be taken on the index colonoscopy. Studies asking the same question in oesophageal1 and combined upper GI cancer2 suggest 6 and 7 biopsies respectively. Aims & Methods: To aim of this study was to suggest the optimal number of biopsies necessary. Data was collected on all colonoscopies with a diagnosis of suspected cancer over a 26 month period. Histological data was collected for initial and repeat biopsies and subsequent surgical specimens. The patients were divided into 2 groups, carcinoma correctly diagnosed at initial biopsy and those needing a second colonoscopy or surgery for diagnosis. Severe dysplasia was counted as a correct diagnosis unless this diagnosis was unsure and a repeat colonoscopy resulted. Results: 217 patients were identified of whom 198 had a histological diagnosis of cancer. Of these 198 patients 182 were correctly diagnosed at index colonoscopy and 16 were diagnosed either on repeat colonoscopy (10) or at surgery (6). 9 patients with suspected cancer not confirmed on initial biopsies neither progressed to surgery nor were re examined endoscopically. 10 patients with suspected cancer were re-examined and diagnosed with non-malignant disease. The number of biopsies in the 16 patients with cancer ‘missed’ at index colonoscopy were statistically lower when compared with the correct group (5.729 0.1392 c/w 4.250 0.4031 p Z 0.0025). Conclusion: This study demonstrates that the sensitivity of diagnosis of a suspected cancer increases with the number of biopsies. A high degree of statistical significance was noted in the lower number of biopsies taken in the group of patients with an initial missed diagnosis. The combined sensitivity of taking 5 or less biopsies (85%) was significantly lower compared to more than 5 (98%) or 6 (99%). We suggest that at least 6 biopsies should be mandatory as a national auditable standard in the context or suspected cancer. References: 1 Quality and safety indicators for endoscopy (2007/2008) - BSG website2 Localizing Colorectal Cancer by Colonoscopy N. Piscatelli, N. Hyman and TOsler. Arch.Surg. 2005;140:932-935 Sensitivity of cancer diagnosis according to number of biopsies taken Number of Biopsies Sensitivity%
2 80
3 86
4 86
5 88
6 98
7 100
8 94
9-13 100
W1541 Endoscopic Submucosal Dissection Using the Newly Developed Ball-Tip Bipolar Current Needle Knife Is Safe and Effective Technique for Large Colorectal Tumors Yutaka Saito, Haruhisa Suzuki, Tsuyoshi Kikuchi, Takahisa Matsuda, Toshio Uraoka, Masakatsu Fukuzawa Background: We previously reported on the safety and usefulness of the bipolar current needle knife (B-knife) for colorectal endoscopic submucosal dissection (ESD). There remains a slight risk of perforation, however, so we developed a Bknife with a ball-shaped tip at the end of the needle which further reduces the risk of perforation. Objective: The aim of this study was to evaluate the safety and efficacy of ESD using the newly developed ball-tip B-knife compared with using a conventional B-knife. Design and setting: Case series conducted at the National Cancer Center Hospital (NCCH), Tokyo, Japan. Patients: Patients with 300 colorectal LSTs were included in this study between January 2003 and November 2007. Through December 2006, 229 colorectal tumors were treated by ESD using a conventional B-knife while 71 colorectal tumors were treated by ESD using the ball-tip B-knife beginning in January 2007. Interventions: ESD procedures were performed using a B-knife and insulation-tip knife (IT knife). After injection of glycerol and sodium hyaluronate acid into the submucosal (sm) layer, a circumferential incision was made and sm dissection was performed. All lesions were determined to be intramucosal or sm superficial by magnified colonoscopy before treatment. Main outcome measurements: We recorded tumor size, operation time, en-bloc resection rate and complications. Results: A total of 300
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