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Endoscopic Or Surgical Resection of Submucosal Adenocarcinoma of the Esophagus Or Stomach? A Decision Analysis
Abstracts
S1424 Percutaneous Endoscopic Cecostomy in Adults: A Case Series Christopher R. Lynch, Robert G. Jones, Kristen Hilden, Jason C. Wills, John C. Fang Background: Percutaneous cecostomy has been reported for treatment of recurrent colonic pseudoobstruction or obstipation. Percutaneous endoscopic cecostomy (PEC) is a potentially attractive alternative to surgical or fluoroscopic cecostomy placement. Two reports describe percutaneous endoscopic cecostomy for management of these problems in children. There are no large series of percutaneous endoscopic cecostomy in adult patients describing the indications, outcomes and complications. Observations: We performed a retrospective review of eight cases of PEC performed from May 2001 through October 2005 at the University of Utah Health Sciences Center. Six were performed for colonic pseudoobstruction and 2 for chronic constipation. Seven of 8 cases were successful and resulted in clinical improvement. The PEC was removed in 3 of 6 cases of pseudoobstruction after clinical improvement (the other 3 remain in place). One patient with chronic constipation required surgical PEC removal at 4 days for fecal spillage resulting in peritonitis despite successful placement. The other patient with chronic constipation died of underlying illness 21 days after placement despite resolution of her obstipation. The only other complications noted were 2 cases of peristomal infection successfully treated with oral antibiotics. Conclusions: Percutaneous endoscopic cecostomy is a viable alternative to surgically or fluoroscopically placed cecostomy in patients with recurrent colonic pseudoobstruction or chronic intractable constipation.
S1426 Endoscopic Or Surgical Resection of Submucosal Adenocarcinoma of the Esophagus Or Stomach? A Decision Analysis Heiko Pohl, Bertram Wiedenmann, Thomas Roesch Background: Endoscopic mucosal resection (EMR) offers a potential cancer resection in the esophagus and stomach in early stages with low morbidity and mortality. Increasing tumor depth increases the chance of lymph node invasion. Disease recurrence and survival depend on the rate of lymph node involvement. Surgery offers complete resection of the tumor and of affected nodes; however, with an upfront risk of operative mortality. Objective: to compare the outcome of EMR and surgery for submucosal esophageal and gastric cancers dependent on the rate of node involvement. Methods: We developed a simple decision analysis model using quality adjusted life years (QALY) as the major outcome variable. Probability estimates were based on published information regarding surgical mortality (4%), the likelihood of lymph node involvement (10%), and the 5-year survival with positive lymph nodes after resection (43%). In the base case analysis we assumed a 1.5 fold increased recurrence rate after EMR compared to surgery. In sensitivity analysis, the results were tested over a broad range of plausible assumptions. Results: In the base case analysis performing EMR resulted in a gain of 1.5 QALY. The major variables influencing the outcome are the difference in recurrent disease as reflected by the probability of node involvement and operative mortality. Assuming a 20% chance of recurrent disease after surgical resection and 4% operative mortality, the chance for recurrent cancer after EMR has to be less then 30% to be the preferred strategy. Higher recurrence rates allow less absolute increase in disease recurrence after EMR for it to remain superior. Assuming a higher chance of lymph node involvement of 40%, low mortality surgery is the preferred strategy if it has an 8% lower recurrence rate compared to EMR. Conclusion: With low surgical mortality rates (!5%) and low disease recurrence after surgery (!20%), EMR offers a promising alternative to surgery only if the difference in recurrence rate between EMR and surgery is low (!10% absolute difference).
S1427 Colonoscopic Perforation Requiring Surgery: Rates, Causes and Consequences. A National Series Sven Adamsen, Karin Mosbach, Palle Miliam, Hart-Hansen Ole
S1425 Diagnostic Value of Endoscopic Mucosal Resection in Low Grade Dysplasia of Gastric Mucosa Byoung Kuk Jang, Yeong Seok Lee, Seong Yeol Kim, Hong Sug Lee, Woo Jin Chung, Kyung Sik Park, Kwang Bum Cho, Jae Seok Hwang, Sung Hoon Ahn, Yu Na Kang Background: The high grade dysplasia has been regarded as a premalignant lesion because of 75% - 100% of malignant transformation rate within two years. Therefore, surgery or endoscopic therapy is recommended to treat the high grade dysplasia. On the other hand, it has been reported that low grade dysplasia has relative low risk of malignant transformation. But various histologic grades might be presented at single dysplastic lesion and so the endoscopic forceps biopsy could not represent whole pathologic lesion. Thus we evaluate the histologic discrepancy between forceps biopsy and the endoscopic mucosal resection in patients with low grade dysplasia. Methods: We reviewed retrospectively 142 cases (M:F Z 84:58) undergone endoscopic mucosal resection after diagnosed as low grade dysplasia by endoscopic forceps biopsy from 1998 to 2005. Results: The mean age of patients was 62.6 G 8.8 (28-77 years) years old . Of the 142 patients, the pathologic results through the endoscopic mucosal resection showed 7 cases (4.9%) of adenocarcinoma, 15 cases (10.6%) of high grade dysplasia, 102 cases (71.8%) low grade dysplasia, 4 cases (2.8%) of hyperplastic polyp, 14 case (9.9%) of chronic gastritis. Twenty two cases (15.5%) among 142 cases were upgraded in the histologic staging to carcinoma or high grade dysplasia. Conclusion: Although low grade dysplasia was diagnosed initially by endoscopic forceps biopsy, endoscopic mucosal resection was need to confirm accurate diagnosis and treat at once. Because focal high grade dysplasia or adenocarcinoma can be existed around low grade dysplasia lesion.
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The perforation rate in colonoscopy is estimated to 0.03-0.1%, including minimal perforations that do not require surgery. The aims of this study were to estimate the rate of perforations requiring laparotomy, costs in terms of hospital utilization, and to assess the outcomes. Patients and Methods: In 1995-2005, 120 claims due to colonoscopic perforations requiring surgical intervention were filed to the PIA, where compensation for injury during treatment is decided. Numbers of procedures for 2002/2003 were obtained from the National Board of Health. Results: In 117 data was complete. 46% were females (median age 65, range 10-91 years), and 54% males (61, 1-82). ASA groups were I:42%, II:38%, III:18%, not stated: 2%. The number of claims peaked in 2002/2003 with 19/22 in 51.218/56.625 colonoscopies were performed in 48 departments (colonoscopy rate: 1.051/ 100.000). The rate of laparotomy for perforations in 2002-3 was 1:2.630 colonoscopies (0.038%), range 0-1:233 (0.43%). Colonoscopy volume and laparotomy rates did not correlate, but hose with a rate R0.1% all did less than 1.650 procedures yearly. Indications included suspected disease (54%), surveillance after polypectomy or surgery in 34%, and proven or suspected neoplasia in 18%. The endoscopist was a surgeon in 90%, gastroenterologist in 8%, pediatrician (1) or nurse (1); a specialist in 56% or trainee in 43%. Anesthesia was used in 8%. 6% had diverticula. Biopsies had been taken in 10 (9%). 65 (55%) had polypectomy (hot forceps in 11, hot snare in 39, coagulation in 5). Two had piecemeal resection. 35/65 (54%) had R2 polyps. The injury was in the sigmoid in 61%, and in the coecum/ ascending colon in 18%. In 28% it was suspected at the time of endoscopy, while in the rest diagnosis was 24 h delayed (1-240). Surgical procedures included exploration without identifying the perforation in 3 (1 ileostomy), suturing with (11) or without enterostomy (34), and resection with (55) or without enterostomy (14). 5 (4%) had splenectomy due to intraoperative injury. Mean stay was 29 days (3-203). 49 patients required intensive care for 7 days (1-56). After the first procedure, 33% had complications (33% after delayed diagnosis, 24% after immediate (p Z 0.03)). 6 had leaks. 37% stomas became permanent. Continuity was re-established after 130 days (44-237), requiring a hospital stay of 13 days. 4 had re-operative surgery (1 anastomotic leakage). 5 (4%) died. Conclusion: Approximately 0.04% of colonoscopy patients require laparotomy for perforation, but rates per department vary. Costs in terms of surgical procedures, utilization of intensive care units, wards, complications and stoma appliances are considerable.
Volume 63, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY AB105
S1424 Percutaneous Endoscopic Cecostomy in Adults: A Case Series Christopher R. Lynch, Robert G. Jones, Kristen Hilden, Jason C. Wills, John C. Fang Background: Percutaneous cecostomy has been reported for treatment of recurrent colonic pseudoobstruction or obstipation. Percutaneous endoscopic cecostomy (PEC) is a potentially attractive alternative to surgical or fluoroscopic cecostomy placement. Two reports describe percutaneous endoscopic cecostomy for management of these problems in children. There are no large series of percutaneous endoscopic cecostomy in adult patients describing the indications, outcomes and complications. Observations: We performed a retrospective review of eight cases of PEC performed from May 2001 through October 2005 at the University of Utah Health Sciences Center. Six were performed for colonic pseudoobstruction and 2 for chronic constipation. Seven of 8 cases were successful and resulted in clinical improvement. The PEC was removed in 3 of 6 cases of pseudoobstruction after clinical improvement (the other 3 remain in place). One patient with chronic constipation required surgical PEC removal at 4 days for fecal spillage resulting in peritonitis despite successful placement. The other patient with chronic constipation died of underlying illness 21 days after placement despite resolution of her obstipation. The only other complications noted were 2 cases of peristomal infection successfully treated with oral antibiotics. Conclusions: Percutaneous endoscopic cecostomy is a viable alternative to surgically or fluoroscopically placed cecostomy in patients with recurrent colonic pseudoobstruction or chronic intractable constipation.
S1426 Endoscopic Or Surgical Resection of Submucosal Adenocarcinoma of the Esophagus Or Stomach? A Decision Analysis Heiko Pohl, Bertram Wiedenmann, Thomas Roesch Background: Endoscopic mucosal resection (EMR) offers a potential cancer resection in the esophagus and stomach in early stages with low morbidity and mortality. Increasing tumor depth increases the chance of lymph node invasion. Disease recurrence and survival depend on the rate of lymph node involvement. Surgery offers complete resection of the tumor and of affected nodes; however, with an upfront risk of operative mortality. Objective: to compare the outcome of EMR and surgery for submucosal esophageal and gastric cancers dependent on the rate of node involvement. Methods: We developed a simple decision analysis model using quality adjusted life years (QALY) as the major outcome variable. Probability estimates were based on published information regarding surgical mortality (4%), the likelihood of lymph node involvement (10%), and the 5-year survival with positive lymph nodes after resection (43%). In the base case analysis we assumed a 1.5 fold increased recurrence rate after EMR compared to surgery. In sensitivity analysis, the results were tested over a broad range of plausible assumptions. Results: In the base case analysis performing EMR resulted in a gain of 1.5 QALY. The major variables influencing the outcome are the difference in recurrent disease as reflected by the probability of node involvement and operative mortality. Assuming a 20% chance of recurrent disease after surgical resection and 4% operative mortality, the chance for recurrent cancer after EMR has to be less then 30% to be the preferred strategy. Higher recurrence rates allow less absolute increase in disease recurrence after EMR for it to remain superior. Assuming a higher chance of lymph node involvement of 40%, low mortality surgery is the preferred strategy if it has an 8% lower recurrence rate compared to EMR. Conclusion: With low surgical mortality rates (!5%) and low disease recurrence after surgery (!20%), EMR offers a promising alternative to surgery only if the difference in recurrence rate between EMR and surgery is low (!10% absolute difference).
S1427 Colonoscopic Perforation Requiring Surgery: Rates, Causes and Consequences. A National Series Sven Adamsen, Karin Mosbach, Palle Miliam, Hart-Hansen Ole
S1425 Diagnostic Value of Endoscopic Mucosal Resection in Low Grade Dysplasia of Gastric Mucosa Byoung Kuk Jang, Yeong Seok Lee, Seong Yeol Kim, Hong Sug Lee, Woo Jin Chung, Kyung Sik Park, Kwang Bum Cho, Jae Seok Hwang, Sung Hoon Ahn, Yu Na Kang Background: The high grade dysplasia has been regarded as a premalignant lesion because of 75% - 100% of malignant transformation rate within two years. Therefore, surgery or endoscopic therapy is recommended to treat the high grade dysplasia. On the other hand, it has been reported that low grade dysplasia has relative low risk of malignant transformation. But various histologic grades might be presented at single dysplastic lesion and so the endoscopic forceps biopsy could not represent whole pathologic lesion. Thus we evaluate the histologic discrepancy between forceps biopsy and the endoscopic mucosal resection in patients with low grade dysplasia. Methods: We reviewed retrospectively 142 cases (M:F Z 84:58) undergone endoscopic mucosal resection after diagnosed as low grade dysplasia by endoscopic forceps biopsy from 1998 to 2005. Results: The mean age of patients was 62.6 G 8.8 (28-77 years) years old . Of the 142 patients, the pathologic results through the endoscopic mucosal resection showed 7 cases (4.9%) of adenocarcinoma, 15 cases (10.6%) of high grade dysplasia, 102 cases (71.8%) low grade dysplasia, 4 cases (2.8%) of hyperplastic polyp, 14 case (9.9%) of chronic gastritis. Twenty two cases (15.5%) among 142 cases were upgraded in the histologic staging to carcinoma or high grade dysplasia. Conclusion: Although low grade dysplasia was diagnosed initially by endoscopic forceps biopsy, endoscopic mucosal resection was need to confirm accurate diagnosis and treat at once. Because focal high grade dysplasia or adenocarcinoma can be existed around low grade dysplasia lesion.
www.giejournal.org
The perforation rate in colonoscopy is estimated to 0.03-0.1%, including minimal perforations that do not require surgery. The aims of this study were to estimate the rate of perforations requiring laparotomy, costs in terms of hospital utilization, and to assess the outcomes. Patients and Methods: In 1995-2005, 120 claims due to colonoscopic perforations requiring surgical intervention were filed to the PIA, where compensation for injury during treatment is decided. Numbers of procedures for 2002/2003 were obtained from the National Board of Health. Results: In 117 data was complete. 46% were females (median age 65, range 10-91 years), and 54% males (61, 1-82). ASA groups were I:42%, II:38%, III:18%, not stated: 2%. The number of claims peaked in 2002/2003 with 19/22 in 51.218/56.625 colonoscopies were performed in 48 departments (colonoscopy rate: 1.051/ 100.000). The rate of laparotomy for perforations in 2002-3 was 1:2.630 colonoscopies (0.038%), range 0-1:233 (0.43%). Colonoscopy volume and laparotomy rates did not correlate, but hose with a rate R0.1% all did less than 1.650 procedures yearly. Indications included suspected disease (54%), surveillance after polypectomy or surgery in 34%, and proven or suspected neoplasia in 18%. The endoscopist was a surgeon in 90%, gastroenterologist in 8%, pediatrician (1) or nurse (1); a specialist in 56% or trainee in 43%. Anesthesia was used in 8%. 6% had diverticula. Biopsies had been taken in 10 (9%). 65 (55%) had polypectomy (hot forceps in 11, hot snare in 39, coagulation in 5). Two had piecemeal resection. 35/65 (54%) had R2 polyps. The injury was in the sigmoid in 61%, and in the coecum/ ascending colon in 18%. In 28% it was suspected at the time of endoscopy, while in the rest diagnosis was 24 h delayed (1-240). Surgical procedures included exploration without identifying the perforation in 3 (1 ileostomy), suturing with (11) or without enterostomy (34), and resection with (55) or without enterostomy (14). 5 (4%) had splenectomy due to intraoperative injury. Mean stay was 29 days (3-203). 49 patients required intensive care for 7 days (1-56). After the first procedure, 33% had complications (33% after delayed diagnosis, 24% after immediate (p Z 0.03)). 6 had leaks. 37% stomas became permanent. Continuity was re-established after 130 days (44-237), requiring a hospital stay of 13 days. 4 had re-operative surgery (1 anastomotic leakage). 5 (4%) died. Conclusion: Approximately 0.04% of colonoscopy patients require laparotomy for perforation, but rates per department vary. Costs in terms of surgical procedures, utilization of intensive care units, wards, complications and stoma appliances are considerable.
Volume 63, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY AB105