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Diagnostic Yield of Advanced Colorectal Neoplasm with Colonoscopy by Indications
Abstracts
W1140 Complications of Self-Expandable Colorectal Stenting for the Treatment of Acute Large Bowel Obstruction Cheol-hyun Kim, Jong-Jae Park, Yeon-Seok Seo, Yoon-Jeong Jang, Ji-Yeon Lee, Jin-Yong Kim, Jae-Seon Kim, Young-Tae Bak Introduction: Placement of self-expanding metallic colorectal stents (colorectal stenting) is established both as an effective palliative alternative to surgery and also as a ¡ bridge to surgery¡Gin acute obstruction. But, severe complications may occur during colorectal stenting (perforation, bleeding, stent malposition) or later (stent migration, bleeding, perforation, stent occlusion). Aims & Methods: We evaluated retrospectively clinical outcomes of colorectal stenting for the treatment of acute large bowel obstruction. From March 2002 to May 2004, colorectal stenting was attempted in 33 patients (M:F Z 14:19, mean age 69 years) using a covered (18-22 mm in diameters) in 9 patients or noncovered (18-24 mm in diameters) metallic stents in 24 patients. Results: Sites of obstruction were rectum (n Z 9), sigmoid (n Z 14), descending colon (n Z 5), splenic flexure (n Z 3), ascending colon (n Z 2). Causes of obstruction were colorectal cancer (n Z 27), metastatic cancer (n Z 4), benign stricture (n Z 2). Technical success was achieved in 31/33 (94%) patients except two patients with obstruction of splenic flexure and ascending colon. In these two patients, the guide wire passage was impossible due to anatomical problems. Clinical decompression was demonstrated in 94% (29/31 patients). One patient who failed to decompress in spite of adequate stenting and the other patient with long stenotic segment of ascending colon required surgery. As a procedure-related complication, perforation developed in one patient (3%). Within 7 days after stenting, spontaneous passing out of the stent outside of body occurred in 4 patients (12%, 4/33), but these patients were clinically decompressed at the time of surgery. 16/33 (48%) patients received stents as a palliative measure. During the F/U of these 16 patients for a mean period of 12 months, migration occurred in 6 patients (38%, covered/noncovered stents: 3/3), tumor ingrowth in 5 patients (31%, covered/noncovered stents: 1/4), outgrowth in 1 patient (6%, noncovered stent), and delayed perforation in 1 patient. The delayed perforation occurred in a patient who has been receiving chemotherapy for rectal cancer 1 month after removal of distally migrated 2nd stent. Conclusion: Although placement of self-expanding metallic colorectal stents would be relatively safe and effective procedure to relieve the colorectal obstruction, long-term complications such as stent migration, tumor ingrowth and stent-induced perforation remain to be solved.
W1141 A Unique Method of Endoscopic Resection Using Single Channel Colonoscope and Grasp Forcep for Rectal Carcinoid Tumor Chang-Keun Park, Sae-Hwan Kim, Mi-Hun Lee, Seung-Yup Lee, Hyun-Sui Kim, Sang-Moon Lee Background: Recent widespread colonoscopy has revealed more rectal carcinoid tumors at earlier stage. Small(!1 cm) rectal carcinoid tumors confined to submucosa are good candidate for endoscopic submucosal resection. But complete resection rate of these submucosal tumors is inferior to that of mucosal tumors despite several options of endoscopic resection technique. So, we have tried new endoscopic resection method for rectal carcinoid tumor and compared its efficacy with that of conventional strip biopsy. Patients and methods: We have performed conventional strip biopsy (September 1996 through August 2004) in ten patients with rectal carcinoid tumor and new endoscopic resection method (September 2003 to October 2004) in eight patients. Tumor size, lower tumor free margin, and lateral tumor free margin were measured microscopically from resected specimens. Our new method are as follows, 1) Inject epinephrine-mixed saline to submucosa and precut with needle type knife around the tumor, 2) Withdraw the scope from patient and preloop snare at tip of the scope, 3) Reinsert the scope and the externally adherent snare, 4) Introduce a grasp forcep through the working channel of the scope, and then grasp the precut lesion, 5) Pull the forcep to raise the lesion from surrounding rectal mucosa, 6) Open snare wire and slide the snare sheath through the shaft of the scope and the grasp forcep up to the lesion by another assistant (The shaft of the scope and the forcep act like guidewire), 7) Close snare wire at the base of raised lesion and resect it. Results: Tumor size was larger in new method group(6.01 ¡3/4 1.71 mm) than in conventional method group (4.64 ¡3/4 2.25 mm), but statistically not significant. Lower tumor free margin (1.32 ¡3/4 0.96 mm versus 0.57 3/4 0.62 mm, P ! 0.05) and lateral tumor free margin (2.41 ¡3/4 0.48 versus 0.95 ¡3/4 0.93, P ! 0.01) were larger in new method group. Complete resection rate(100% versus 60%, P ! 0.05) was higher in new method group. Complications were equally 4 cases in each group and all cases were immediate minor bleeding treated endoscopically. Conclusions: Our new endoscopic resection method is simple, safe and effective for resection of small rectal carcinoid tumor, and requires minimal instrument.
AB262 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
W1142 Short Term Colonoscopic Follow Up After Anti-Tuberculous Medication in Patients with Atypical Ulcers on IC Valve and Terminal Ileum YoungSook Park, Yun Ju Jo, Seong Hwan Kim, Moon Hee Song, Han Hyo Lee Backgrounds/Aim: Atypical ulcers on IC valve and terminal ileum in patients with chronic diarrhea and RLQ pain do not provide confirmative diagnosis between tuberculosis and other inflammatory bowel disease. In Korea, pulmonary and extrapulmonary tuberculosis are not rare. So short term anti-tuberculosis medication is known to be helpful for making differentiation. We analyzed the colonoscopic findings before and after the tuberculosis treatment in patients with intestinal tuberculosis and atypical inflammatory bowel disease. Methods: From March 2002 to October 2004, We analyzed the colonoscopic findings before and after the tuberculosis treatment in 23 patients with intestinal tuberculosis and 25 patients with atypical inflammatory bowel disease. Mean duration for tuberculous medication is 107.3 days. Results: Ulcers are located at IC valve, AC and terminal ielum in both groups. There are no rectal and perianal lesion in both groups. Ulcers show geographic and irregular shape. Aphthous ulcers are common in IBD patients and transverse ulcers are common in intestinal tuberculosis patients (p ! 0.05). After tuberculous medication, there are scarring and inflammatory polyps in patients with intestinal tuberculosis, but active ulcers are remained and sometimes aggravated in patients with inflammatory bowel disease (p ! 0.05). On follow up, patients with inflammatory bowel disease were diagnosed as Crohn’s disease in 13 patients, Bechet’s enterocolitis in 8 patients and simple ulcers in 4 patients. Conclusions: In cases of atypical ulcers around IC valve, 3 months of anti-tuberculous treatment and colonoscopic follow up are valuable for making confirmative diagnosis and therapeutic plan.
W1143 Diagnostic Yield of Advanced Colorectal Neoplasm with Colonoscopy by Indications Dong Il Park, Yong-Ho Kim, Hyun Soo Kim, Won Ho Kim, Tae Il Kim, Hyo Jong Kim, Suk-Kyun Yang, Jeong-Sik Byeon, Moon Sung Lee, Il Kwon Jung, Moon Kwan Chung, Sung-Ae Jung, Yoon Tae Jeen, Jai Hyun Choi, Hwang Choi, Dong Soo Han, Jae Suk Song Background and Aims: The factors that best predict the presence of colorectal cancers and adenomas at colonoscopy are different. We conducted a prospective multicenter study to evaluate which indications were most closely associated with advanced colorectal neoplasm including colorectal cancer in patients undergoing colonoscopy. Methods: 6752 patients were enrolled in this study between July 2003 and March 2004 from 11 tertiary medical centers in Korea. They were recruited according to itemized 11 colonoscopic indications (1. bowel habit change, 2. stool caliber change, 3. melena/hematochezia, 4. tenesmus, 5. abdominal pain, 6. iron deficiency anemia, 7. past history of colorectal neoplasm, 8. familial history of colorectal cancer, 9. diagnosis and follow-up of inflammatory bowel disease, 10. referred for colonoscopy from primary physician, 11. other indications). The term ‘advanced adenoma’ is used to refer to tubular adenomas that were 10 mm or more in diameter or to tubulovillous, villous or severely dysplastic adenomas irrespective of size. Cancer was defined as the invasion of malignant cells beyond the muscularis mucosa. Advanced colorectal neoplasm was defined as advanced adenoma or invasive cancer. Results: Advance colorectal neoplasm was found in 422/6752 patients (368 advanced adenomas plus 54 carcinomas, 6.25%). In the multivariate analysis, age O 60 (Odds ratio 1.034, 95% confidence interval 1.025-1.043, p ! 0.0001), female gender (OR 0.501, 95% CI 0.387-0.647, p ! 0.0001), diagnosis and follow-up of inflammatory bowel disease (OR 3.126, 95% CI 1.723-5.674, p ! 0.001), referred for colonoscopy from primary physician (OR 1.776, 95% CI 1.135-2.777, p ! 0.05), other indications (OR 2.110, 95% CI 1.085-4.103, p ! 0.05) were associated with advanced colorectal neoplasm. Conclusions: Age, gender, diagnosis and follow-up of inflammatory bowel disease, referred for colonoscopy from primary physician and other indications are important independent predictors of advanced colorectal neoplasm in patients undergoing colonoscopy.
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W1140 Complications of Self-Expandable Colorectal Stenting for the Treatment of Acute Large Bowel Obstruction Cheol-hyun Kim, Jong-Jae Park, Yeon-Seok Seo, Yoon-Jeong Jang, Ji-Yeon Lee, Jin-Yong Kim, Jae-Seon Kim, Young-Tae Bak Introduction: Placement of self-expanding metallic colorectal stents (colorectal stenting) is established both as an effective palliative alternative to surgery and also as a ¡ bridge to surgery¡Gin acute obstruction. But, severe complications may occur during colorectal stenting (perforation, bleeding, stent malposition) or later (stent migration, bleeding, perforation, stent occlusion). Aims & Methods: We evaluated retrospectively clinical outcomes of colorectal stenting for the treatment of acute large bowel obstruction. From March 2002 to May 2004, colorectal stenting was attempted in 33 patients (M:F Z 14:19, mean age 69 years) using a covered (18-22 mm in diameters) in 9 patients or noncovered (18-24 mm in diameters) metallic stents in 24 patients. Results: Sites of obstruction were rectum (n Z 9), sigmoid (n Z 14), descending colon (n Z 5), splenic flexure (n Z 3), ascending colon (n Z 2). Causes of obstruction were colorectal cancer (n Z 27), metastatic cancer (n Z 4), benign stricture (n Z 2). Technical success was achieved in 31/33 (94%) patients except two patients with obstruction of splenic flexure and ascending colon. In these two patients, the guide wire passage was impossible due to anatomical problems. Clinical decompression was demonstrated in 94% (29/31 patients). One patient who failed to decompress in spite of adequate stenting and the other patient with long stenotic segment of ascending colon required surgery. As a procedure-related complication, perforation developed in one patient (3%). Within 7 days after stenting, spontaneous passing out of the stent outside of body occurred in 4 patients (12%, 4/33), but these patients were clinically decompressed at the time of surgery. 16/33 (48%) patients received stents as a palliative measure. During the F/U of these 16 patients for a mean period of 12 months, migration occurred in 6 patients (38%, covered/noncovered stents: 3/3), tumor ingrowth in 5 patients (31%, covered/noncovered stents: 1/4), outgrowth in 1 patient (6%, noncovered stent), and delayed perforation in 1 patient. The delayed perforation occurred in a patient who has been receiving chemotherapy for rectal cancer 1 month after removal of distally migrated 2nd stent. Conclusion: Although placement of self-expanding metallic colorectal stents would be relatively safe and effective procedure to relieve the colorectal obstruction, long-term complications such as stent migration, tumor ingrowth and stent-induced perforation remain to be solved.
W1141 A Unique Method of Endoscopic Resection Using Single Channel Colonoscope and Grasp Forcep for Rectal Carcinoid Tumor Chang-Keun Park, Sae-Hwan Kim, Mi-Hun Lee, Seung-Yup Lee, Hyun-Sui Kim, Sang-Moon Lee Background: Recent widespread colonoscopy has revealed more rectal carcinoid tumors at earlier stage. Small(!1 cm) rectal carcinoid tumors confined to submucosa are good candidate for endoscopic submucosal resection. But complete resection rate of these submucosal tumors is inferior to that of mucosal tumors despite several options of endoscopic resection technique. So, we have tried new endoscopic resection method for rectal carcinoid tumor and compared its efficacy with that of conventional strip biopsy. Patients and methods: We have performed conventional strip biopsy (September 1996 through August 2004) in ten patients with rectal carcinoid tumor and new endoscopic resection method (September 2003 to October 2004) in eight patients. Tumor size, lower tumor free margin, and lateral tumor free margin were measured microscopically from resected specimens. Our new method are as follows, 1) Inject epinephrine-mixed saline to submucosa and precut with needle type knife around the tumor, 2) Withdraw the scope from patient and preloop snare at tip of the scope, 3) Reinsert the scope and the externally adherent snare, 4) Introduce a grasp forcep through the working channel of the scope, and then grasp the precut lesion, 5) Pull the forcep to raise the lesion from surrounding rectal mucosa, 6) Open snare wire and slide the snare sheath through the shaft of the scope and the grasp forcep up to the lesion by another assistant (The shaft of the scope and the forcep act like guidewire), 7) Close snare wire at the base of raised lesion and resect it. Results: Tumor size was larger in new method group(6.01 ¡3/4 1.71 mm) than in conventional method group (4.64 ¡3/4 2.25 mm), but statistically not significant. Lower tumor free margin (1.32 ¡3/4 0.96 mm versus 0.57 3/4 0.62 mm, P ! 0.05) and lateral tumor free margin (2.41 ¡3/4 0.48 versus 0.95 ¡3/4 0.93, P ! 0.01) were larger in new method group. Complete resection rate(100% versus 60%, P ! 0.05) was higher in new method group. Complications were equally 4 cases in each group and all cases were immediate minor bleeding treated endoscopically. Conclusions: Our new endoscopic resection method is simple, safe and effective for resection of small rectal carcinoid tumor, and requires minimal instrument.
AB262 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
W1142 Short Term Colonoscopic Follow Up After Anti-Tuberculous Medication in Patients with Atypical Ulcers on IC Valve and Terminal Ileum YoungSook Park, Yun Ju Jo, Seong Hwan Kim, Moon Hee Song, Han Hyo Lee Backgrounds/Aim: Atypical ulcers on IC valve and terminal ileum in patients with chronic diarrhea and RLQ pain do not provide confirmative diagnosis between tuberculosis and other inflammatory bowel disease. In Korea, pulmonary and extrapulmonary tuberculosis are not rare. So short term anti-tuberculosis medication is known to be helpful for making differentiation. We analyzed the colonoscopic findings before and after the tuberculosis treatment in patients with intestinal tuberculosis and atypical inflammatory bowel disease. Methods: From March 2002 to October 2004, We analyzed the colonoscopic findings before and after the tuberculosis treatment in 23 patients with intestinal tuberculosis and 25 patients with atypical inflammatory bowel disease. Mean duration for tuberculous medication is 107.3 days. Results: Ulcers are located at IC valve, AC and terminal ielum in both groups. There are no rectal and perianal lesion in both groups. Ulcers show geographic and irregular shape. Aphthous ulcers are common in IBD patients and transverse ulcers are common in intestinal tuberculosis patients (p ! 0.05). After tuberculous medication, there are scarring and inflammatory polyps in patients with intestinal tuberculosis, but active ulcers are remained and sometimes aggravated in patients with inflammatory bowel disease (p ! 0.05). On follow up, patients with inflammatory bowel disease were diagnosed as Crohn’s disease in 13 patients, Bechet’s enterocolitis in 8 patients and simple ulcers in 4 patients. Conclusions: In cases of atypical ulcers around IC valve, 3 months of anti-tuberculous treatment and colonoscopic follow up are valuable for making confirmative diagnosis and therapeutic plan.
W1143 Diagnostic Yield of Advanced Colorectal Neoplasm with Colonoscopy by Indications Dong Il Park, Yong-Ho Kim, Hyun Soo Kim, Won Ho Kim, Tae Il Kim, Hyo Jong Kim, Suk-Kyun Yang, Jeong-Sik Byeon, Moon Sung Lee, Il Kwon Jung, Moon Kwan Chung, Sung-Ae Jung, Yoon Tae Jeen, Jai Hyun Choi, Hwang Choi, Dong Soo Han, Jae Suk Song Background and Aims: The factors that best predict the presence of colorectal cancers and adenomas at colonoscopy are different. We conducted a prospective multicenter study to evaluate which indications were most closely associated with advanced colorectal neoplasm including colorectal cancer in patients undergoing colonoscopy. Methods: 6752 patients were enrolled in this study between July 2003 and March 2004 from 11 tertiary medical centers in Korea. They were recruited according to itemized 11 colonoscopic indications (1. bowel habit change, 2. stool caliber change, 3. melena/hematochezia, 4. tenesmus, 5. abdominal pain, 6. iron deficiency anemia, 7. past history of colorectal neoplasm, 8. familial history of colorectal cancer, 9. diagnosis and follow-up of inflammatory bowel disease, 10. referred for colonoscopy from primary physician, 11. other indications). The term ‘advanced adenoma’ is used to refer to tubular adenomas that were 10 mm or more in diameter or to tubulovillous, villous or severely dysplastic adenomas irrespective of size. Cancer was defined as the invasion of malignant cells beyond the muscularis mucosa. Advanced colorectal neoplasm was defined as advanced adenoma or invasive cancer. Results: Advance colorectal neoplasm was found in 422/6752 patients (368 advanced adenomas plus 54 carcinomas, 6.25%). In the multivariate analysis, age O 60 (Odds ratio 1.034, 95% confidence interval 1.025-1.043, p ! 0.0001), female gender (OR 0.501, 95% CI 0.387-0.647, p ! 0.0001), diagnosis and follow-up of inflammatory bowel disease (OR 3.126, 95% CI 1.723-5.674, p ! 0.001), referred for colonoscopy from primary physician (OR 1.776, 95% CI 1.135-2.777, p ! 0.05), other indications (OR 2.110, 95% CI 1.085-4.103, p ! 0.05) were associated with advanced colorectal neoplasm. Conclusions: Age, gender, diagnosis and follow-up of inflammatory bowel disease, referred for colonoscopy from primary physician and other indications are important independent predictors of advanced colorectal neoplasm in patients undergoing colonoscopy.
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