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Comparison of Endoscopic Submucosal Dissection (ESD) Using Sodium Hyaluronate and Needle-Knife Versus Endoscopic Mucosal Resection (EMR) for Laterally Spreading Tumor (LST) of the Colon
Abstracts
test performance in screening average-risk population is not known. We aimed to compare the performance characteristics of the reference Guaiac-based FOBT (Hemoccult II) and the qi-FOBT (OC-SENSA) using different positivity cuff-off values for detection of ACRN in average risk population undergoing screening colonoscopy and to determine the number of qi-FOBT needed. Methods: A total of 827 consecutive average-risk patients from four centres who visited to be taken screening colonoscopy also provided the stool samples without dietary restrictions. Stool specimens from 3 consecutive bowel movements were collected and applied on Hemoccult II test card windows and the qi-FOBT sampling probes at the same time. Sensitivity, specificity, positive and negative predictive values, likelihood ratios and 95% CIs of fecal hemoglobin measurements for ACRN, their relationship to the amount of fecal hemoglobin were measured. In addition, the number of qi-FOBTs needed was determined. Results: 78 ACRN (15 cancers and 63 advanced adenomas) were identified during screening colonoscopy. Sensitivity/specificity/positive and negative likelihood ratio/positive and negative predictive values for detecting ACRN by Hemoccult II were 30.7%/83.7%/1.89/0.828/16.2%/92.2%, respectively. Using 3 qiFOBTs and a hemoglobin threshold of 75 and 100 ng/mL, sensitivity/specificity/ positive and negative likelihood ratio/positive and negative predictive values for detecting ACRN were 42.5%/90.1%/4.29/0.64/31.7%/93.5% and 39.0%/91.2%/4.41/ 0.67/31.9%/93.4% respectively. The area under the curve measurements of 1st test, 1st and 2nd tests, and all 3 tests for ACRN were 0.6959, 0.7239, and 0.7379 (pZ0.129), respectively. With threshold of 75 ng/mL and 100 ng/mL, one test of qiFOBT showed similar sensitivity, better specificity, and better positive predictive value for detecting ACRN than 3 sets of Hemoccult II testings. Conclusion: Qi-FOBT provided the better performance characteristics for detecting ACRN in average risk populations than reference Guaiac-based FOBT. Just single testing of qi-FOBT considered to be enough in this population.
T1369 The Clinical and Pathological Features of Depressed Type Colorectal Neoplasms and the Significance of Pit Pattern Diagnosis Shin-Ei Kudo, Orie Takemura, Nobunao Ikehara, Kazuo Ohtsuka, Hiroshi Kashida, Shigeharu Hamatani Introduction: At one time, most colorectal carcinomas were thought to develop from protruded polyps. Recent advances in endoscopic diagnosis and colonoscope technology have revealed the existence of many flat and depressed types of neoplasms. GIE, published in Oct. 2008, widely introduced those lesions as nonpolypoid mucosal colorectal neoplasms (NMCN). We have detected more than 600 depressed type neoplasms at Akita Red Cross Hospital and our Unit during 1985-2008. Depressed type neoplasms are assumed to emerge directly from normal epithelium without going through a stage of adenoma, which is mentioned as the ‘‘de novo’’ carcinogenesis. ‘‘De novo’’ sequence possibly may be main route of development of colorectal cancer. Aim: To evaluate the clinical and pathological natures and validity of pit pattern diagnosis (Kudo’s classification) on depressed type colorectal neoplasms. Methods: From Apr. 2001 to Jun. 2008, we retrospectively evaluated 10,212 colorectal neoplasms, excluding advanced cancers, which removed endoscopically or surgically at our Unit. We evaluated a correlation between submucosal invasive rates and size, morphological features and pit patterns. Result: The submucosal invasive rate of depressed type neoplasms reached 64.1% (98/153). Meanwhile, the overall invasive rates of flat and protruded type neoplasms were 2.6% (98/3772) and 3.2% (204/6288), respectively. The submucosal invasive rates were 6.5% in lesions not exceeding 5 mm, 60.8% in those from 6-10 mm, and 89.2% in those from 11-15 mm in diameter. In contrast, the invasive rates in flat type and protruded type neoplasms were 0% and 0.04% for those less than 5mm in diameter. Most (90.9% and 91.7%) of the protruded and flat type neoplasms showed type IIIL or IV pit patterns, whereas 94.3% of the depressed type neoplasms were characterized by type IIIS, VI, or VN pit patterns. Only 0.63% of the lesions with type IIIL, and IV pit patterns were invasive cancers. On the other hand, 2.4% of the lesions with type IIIS pit pattern, 34.5% of those of type VI and 91.1% of those of type VN were invasive carcinomas regardless of its gross appearance. Type VI reflected histological structural atypism outgrowth of cancerous glands, and type VN, which lacks of superficial microstructure, reflected exposing desmoplastic reaction of deeply invasive submucosal components to the surface. Conclusion: We have revealed that depressed type neoplasms grow rapidly and invade the submucosa even at an early stage. With magnifying colonoscopies, the pit pattern diagnosis, which correlated well with the histological diagnosis, is available for assessing the depth of the lesions and selecting appropriate therapies.
T1370 Comparison of Endoscopic Submucosal Dissection (ESD) Using Sodium Hyaluronate and Needle-Knife Versus Endoscopic Mucosal Resection (EMR) for Laterally Spreading Tumor (LST) of the Colon Ayako Okuda, Makoto Nishimura, Hideki Kitada, Shuya Yoshinaga, Kouichi Nonaka, Michio Hifumi
www.giejournal.org
Background and Aims: Since en-bloc resection by endoscopic submucosal dissection (ESD) facilitates an accurate histological evaluation, this technique has been developed to treat GI tract lesions. The ESD method using sodium hyaluronate and a needle-knife was applied for lateral spreading tumors (LST) of the colorectum. This study compared outcomes between ESD and EMR for colorectal LST treated at our institution. Methods: Between July 2004 and July 2008, we treated 106 patients (66 males/40 females; mean age: 67.3 years, range 40-84 years) with LST by ESD or EMR at our institution. The size of the resected specimen, en-bloc resection rate, negative horizontal margin rate, complications, and histopathological findings were analyzed and compared between the ESD group and EMR group. Results: In this study, ESD was performed on 60 patients, and EMR was performed on 46 patients. The mean resected specimen size was 29.1mm (range 10-65 mm in diameter) for ESD and 18.2mm (range 10-55 mm in diameter) for EMR (p!0.01). The en-bloc rate was 90.0% with ESD and 71.7% with EMR (p!0.01). Histopathologically, there were 3 carcinomas,13 carcinomas in adenoma and 41 adenomas in the ESD group, and 1 carcinoma, 6 carcinomas in adenoma and 34 adenomas in the EMR group. The negative horizontal margin rate was 73.3% for ESD and 67.3% for EMR (p!0.01). Three cases undergoing ESD and two cases undergoing EMR demonstrated a significant quantity of active bleeding during the procedure, but endoscopic hemostasis was successful in all cases. Conclusions: Our results indicate that ESD using sodium hyaluronate and needleknife is feasible for colorectal LST without any greater risk than the EMR technique. Therefore, we conclude that our ESD method might be a more reliable treatment for colorectal LST than EMR.
T1371 Effectiveness of Endoscopic Submucosal Dissection As An Alternative to Traditional Surgery for Large Lateral Spreading Polyps and Early Malignancies of the Colon and Rectum in the United States Mainor R. Antillon, Wilson P. Pais, Alberto A. Diaz-Arias, Seema S. Tekwani, Jamal A. Ibdah, John B. Marshall Background: Endoscopic submucosal dissection (ESD), a type of intraluminal endoscopic surgery, was developed in Japan for en-bloc removal of GI tumors as an alternative to conventional surgical removal. The technique employs an electrosurgical knife to dissect the submucosal layer beneath the lesion, and is capable of removing en-bloc (one piece) much larger tumors than the older technique of endoscopic mucosal resection. Though initially done for gastric tumors, ESD has now been applied to lesions elsewhere in the gut. There is little published experience with ESD outside of Asia. Objective: Our purpose was to assess the effectiveness and safety of ESD for the removal of large lateral spreading polyps and early malignancies at our American academic med center. Methods: Retrospective analysis from chart audits of 86 consecutive patients who underwent colorectal ESD between June 2006 and November 2008. All procedures were performed by one endoscopist (MRA). Results: There were 63 colonic and 23 rectal lesions. Of the latter, 10 extended to the anal canal. Seventy of the colorectal lesions were benign adenomas and 16 contained cancer. The mean size of lesions was 4.2-cm (range, 1.5- to 14-cm). Procedural success was 100%. The rate of en-bloc resection was 86.0% (74/86), and en-bloc resection with tumor-free lateral/basal margins was 62.8% (54/86). All tumors which extended to the dentate line were successfully removed, avoided the need for colostomy, and continence was preserved. The complications in our series included perforations in 5.8% (5/86). Surgery was performed in 3, including two early in our experience. The other two were medically managed. Bleeding was seen in 3.5% (3/86). Two required 2 units of packed RBCs each; no other therapy was needed. Mean length of hospitalization was 1.3 days. We are in the process of collecting long-term outcome data. To this point, only one patient with a benign lesion was found to have residual polyp tissue at the time of follow-up endoscopy. It was successfully ablated, and subsequent endoscopy has not disclosed recurrence. Five of the patients with malignancies had sm deep cancers for which surgery was recommended. The other cancers, intramucosal cancers and minute sm cancers, have not shown recurrences to this point. Conclusions: ESD performed at our American center shows promising results for removal of lateral spreading colorectal polyps and early cancers as an alternative to surgical removal. En-bloc removal also allows the pathologist to better assess for invasive cancer compared to piecemeal polypectomy. ESD is also applicable when there is rectal involvement to the dentate line.
T1372 Efficacy and Safety of Argon Plasma Coagulation for the Treatment of Hemorrhagic Radiation Proctitis Paulo Correa, Eduardo J. Lobo, Marcelo Averbach, Jose Paccos, Giulio F. Rossini, Oswaldo W. Marques, Pedro Popoutchi Background: Radiation proctitis is the most relevant complication of radiotherapy for malignant pelvic disease and occurs in about 5% to 10% of all patients. It is characterized by bleeding, rectal pain, diarrhea, mucoid discharge and fecal urgency. There is no consensus for the management of this condition and many conservative treatment modalities have been proposed with varying success. Argon
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB279
test performance in screening average-risk population is not known. We aimed to compare the performance characteristics of the reference Guaiac-based FOBT (Hemoccult II) and the qi-FOBT (OC-SENSA) using different positivity cuff-off values for detection of ACRN in average risk population undergoing screening colonoscopy and to determine the number of qi-FOBT needed. Methods: A total of 827 consecutive average-risk patients from four centres who visited to be taken screening colonoscopy also provided the stool samples without dietary restrictions. Stool specimens from 3 consecutive bowel movements were collected and applied on Hemoccult II test card windows and the qi-FOBT sampling probes at the same time. Sensitivity, specificity, positive and negative predictive values, likelihood ratios and 95% CIs of fecal hemoglobin measurements for ACRN, their relationship to the amount of fecal hemoglobin were measured. In addition, the number of qi-FOBTs needed was determined. Results: 78 ACRN (15 cancers and 63 advanced adenomas) were identified during screening colonoscopy. Sensitivity/specificity/positive and negative likelihood ratio/positive and negative predictive values for detecting ACRN by Hemoccult II were 30.7%/83.7%/1.89/0.828/16.2%/92.2%, respectively. Using 3 qiFOBTs and a hemoglobin threshold of 75 and 100 ng/mL, sensitivity/specificity/ positive and negative likelihood ratio/positive and negative predictive values for detecting ACRN were 42.5%/90.1%/4.29/0.64/31.7%/93.5% and 39.0%/91.2%/4.41/ 0.67/31.9%/93.4% respectively. The area under the curve measurements of 1st test, 1st and 2nd tests, and all 3 tests for ACRN were 0.6959, 0.7239, and 0.7379 (pZ0.129), respectively. With threshold of 75 ng/mL and 100 ng/mL, one test of qiFOBT showed similar sensitivity, better specificity, and better positive predictive value for detecting ACRN than 3 sets of Hemoccult II testings. Conclusion: Qi-FOBT provided the better performance characteristics for detecting ACRN in average risk populations than reference Guaiac-based FOBT. Just single testing of qi-FOBT considered to be enough in this population.
T1369 The Clinical and Pathological Features of Depressed Type Colorectal Neoplasms and the Significance of Pit Pattern Diagnosis Shin-Ei Kudo, Orie Takemura, Nobunao Ikehara, Kazuo Ohtsuka, Hiroshi Kashida, Shigeharu Hamatani Introduction: At one time, most colorectal carcinomas were thought to develop from protruded polyps. Recent advances in endoscopic diagnosis and colonoscope technology have revealed the existence of many flat and depressed types of neoplasms. GIE, published in Oct. 2008, widely introduced those lesions as nonpolypoid mucosal colorectal neoplasms (NMCN). We have detected more than 600 depressed type neoplasms at Akita Red Cross Hospital and our Unit during 1985-2008. Depressed type neoplasms are assumed to emerge directly from normal epithelium without going through a stage of adenoma, which is mentioned as the ‘‘de novo’’ carcinogenesis. ‘‘De novo’’ sequence possibly may be main route of development of colorectal cancer. Aim: To evaluate the clinical and pathological natures and validity of pit pattern diagnosis (Kudo’s classification) on depressed type colorectal neoplasms. Methods: From Apr. 2001 to Jun. 2008, we retrospectively evaluated 10,212 colorectal neoplasms, excluding advanced cancers, which removed endoscopically or surgically at our Unit. We evaluated a correlation between submucosal invasive rates and size, morphological features and pit patterns. Result: The submucosal invasive rate of depressed type neoplasms reached 64.1% (98/153). Meanwhile, the overall invasive rates of flat and protruded type neoplasms were 2.6% (98/3772) and 3.2% (204/6288), respectively. The submucosal invasive rates were 6.5% in lesions not exceeding 5 mm, 60.8% in those from 6-10 mm, and 89.2% in those from 11-15 mm in diameter. In contrast, the invasive rates in flat type and protruded type neoplasms were 0% and 0.04% for those less than 5mm in diameter. Most (90.9% and 91.7%) of the protruded and flat type neoplasms showed type IIIL or IV pit patterns, whereas 94.3% of the depressed type neoplasms were characterized by type IIIS, VI, or VN pit patterns. Only 0.63% of the lesions with type IIIL, and IV pit patterns were invasive cancers. On the other hand, 2.4% of the lesions with type IIIS pit pattern, 34.5% of those of type VI and 91.1% of those of type VN were invasive carcinomas regardless of its gross appearance. Type VI reflected histological structural atypism outgrowth of cancerous glands, and type VN, which lacks of superficial microstructure, reflected exposing desmoplastic reaction of deeply invasive submucosal components to the surface. Conclusion: We have revealed that depressed type neoplasms grow rapidly and invade the submucosa even at an early stage. With magnifying colonoscopies, the pit pattern diagnosis, which correlated well with the histological diagnosis, is available for assessing the depth of the lesions and selecting appropriate therapies.
T1370 Comparison of Endoscopic Submucosal Dissection (ESD) Using Sodium Hyaluronate and Needle-Knife Versus Endoscopic Mucosal Resection (EMR) for Laterally Spreading Tumor (LST) of the Colon Ayako Okuda, Makoto Nishimura, Hideki Kitada, Shuya Yoshinaga, Kouichi Nonaka, Michio Hifumi
www.giejournal.org
Background and Aims: Since en-bloc resection by endoscopic submucosal dissection (ESD) facilitates an accurate histological evaluation, this technique has been developed to treat GI tract lesions. The ESD method using sodium hyaluronate and a needle-knife was applied for lateral spreading tumors (LST) of the colorectum. This study compared outcomes between ESD and EMR for colorectal LST treated at our institution. Methods: Between July 2004 and July 2008, we treated 106 patients (66 males/40 females; mean age: 67.3 years, range 40-84 years) with LST by ESD or EMR at our institution. The size of the resected specimen, en-bloc resection rate, negative horizontal margin rate, complications, and histopathological findings were analyzed and compared between the ESD group and EMR group. Results: In this study, ESD was performed on 60 patients, and EMR was performed on 46 patients. The mean resected specimen size was 29.1mm (range 10-65 mm in diameter) for ESD and 18.2mm (range 10-55 mm in diameter) for EMR (p!0.01). The en-bloc rate was 90.0% with ESD and 71.7% with EMR (p!0.01). Histopathologically, there were 3 carcinomas,13 carcinomas in adenoma and 41 adenomas in the ESD group, and 1 carcinoma, 6 carcinomas in adenoma and 34 adenomas in the EMR group. The negative horizontal margin rate was 73.3% for ESD and 67.3% for EMR (p!0.01). Three cases undergoing ESD and two cases undergoing EMR demonstrated a significant quantity of active bleeding during the procedure, but endoscopic hemostasis was successful in all cases. Conclusions: Our results indicate that ESD using sodium hyaluronate and needleknife is feasible for colorectal LST without any greater risk than the EMR technique. Therefore, we conclude that our ESD method might be a more reliable treatment for colorectal LST than EMR.
T1371 Effectiveness of Endoscopic Submucosal Dissection As An Alternative to Traditional Surgery for Large Lateral Spreading Polyps and Early Malignancies of the Colon and Rectum in the United States Mainor R. Antillon, Wilson P. Pais, Alberto A. Diaz-Arias, Seema S. Tekwani, Jamal A. Ibdah, John B. Marshall Background: Endoscopic submucosal dissection (ESD), a type of intraluminal endoscopic surgery, was developed in Japan for en-bloc removal of GI tumors as an alternative to conventional surgical removal. The technique employs an electrosurgical knife to dissect the submucosal layer beneath the lesion, and is capable of removing en-bloc (one piece) much larger tumors than the older technique of endoscopic mucosal resection. Though initially done for gastric tumors, ESD has now been applied to lesions elsewhere in the gut. There is little published experience with ESD outside of Asia. Objective: Our purpose was to assess the effectiveness and safety of ESD for the removal of large lateral spreading polyps and early malignancies at our American academic med center. Methods: Retrospective analysis from chart audits of 86 consecutive patients who underwent colorectal ESD between June 2006 and November 2008. All procedures were performed by one endoscopist (MRA). Results: There were 63 colonic and 23 rectal lesions. Of the latter, 10 extended to the anal canal. Seventy of the colorectal lesions were benign adenomas and 16 contained cancer. The mean size of lesions was 4.2-cm (range, 1.5- to 14-cm). Procedural success was 100%. The rate of en-bloc resection was 86.0% (74/86), and en-bloc resection with tumor-free lateral/basal margins was 62.8% (54/86). All tumors which extended to the dentate line were successfully removed, avoided the need for colostomy, and continence was preserved. The complications in our series included perforations in 5.8% (5/86). Surgery was performed in 3, including two early in our experience. The other two were medically managed. Bleeding was seen in 3.5% (3/86). Two required 2 units of packed RBCs each; no other therapy was needed. Mean length of hospitalization was 1.3 days. We are in the process of collecting long-term outcome data. To this point, only one patient with a benign lesion was found to have residual polyp tissue at the time of follow-up endoscopy. It was successfully ablated, and subsequent endoscopy has not disclosed recurrence. Five of the patients with malignancies had sm deep cancers for which surgery was recommended. The other cancers, intramucosal cancers and minute sm cancers, have not shown recurrences to this point. Conclusions: ESD performed at our American center shows promising results for removal of lateral spreading colorectal polyps and early cancers as an alternative to surgical removal. En-bloc removal also allows the pathologist to better assess for invasive cancer compared to piecemeal polypectomy. ESD is also applicable when there is rectal involvement to the dentate line.
T1372 Efficacy and Safety of Argon Plasma Coagulation for the Treatment of Hemorrhagic Radiation Proctitis Paulo Correa, Eduardo J. Lobo, Marcelo Averbach, Jose Paccos, Giulio F. Rossini, Oswaldo W. Marques, Pedro Popoutchi Background: Radiation proctitis is the most relevant complication of radiotherapy for malignant pelvic disease and occurs in about 5% to 10% of all patients. It is characterized by bleeding, rectal pain, diarrhea, mucoid discharge and fecal urgency. There is no consensus for the management of this condition and many conservative treatment modalities have been proposed with varying success. Argon
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB279