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Expandable Metal Stent Placement for Malignant Colorectal Obstruction - Report of 36 Consecutive Patients
Abstracts
W1096 Predictive Factors for Colorectal Cancers Occurring in Patients After a Clearing Colonoscopy William D. Farrar, Douglas B. Nelson, John H. Bond, Mandeep S. Sawhney
W1098 Expandable Metal Stent Placement for Malignant Colorectal Obstruction - Report of 36 Consecutive Patients Julieta Fe´lix, Jo~ao Deus, Ricardo Gorj~ao, Eduardo Pires, Paulo Ratilal, Luis Novais
Background: A small but finite number of patients develop colorectal cancer (CRC) despite having a clearing colonoscopy. Aim: To evaluate factors associated with CRCs found after a colonoscopy such as staff physician performing the colonoscopy, trainee participation, poor prep or proximal tumor location. Methods: The Minneapolis VA colon cancer registry was used to identify cases who were found to have CRC between 6 and 66 months of a complete, clearing colonoscopy. Controls were patients diagnosed with CRC on their first colonoscopy. Two controls for every case were selected, matched by the year of cancer diagnosis to the year of each case’s initial colonoscopy. Patients with FAP, HNPCC, IBD or anastomotic cancers were excluded. Factors were compared using the chi-squared test. 5-year overall mortality was calculated using a Kaplan-Meier survival analysis and log-rank test. Results: Out of 813 CRC’s between 1/1/1991 and 8/31/2004, 45 cases were identified (5.5%). The average time between colonoscopies was 34 months (Range: 12-64 months). Compared to 90 controls, CRCs in cases were more likely to be located in the cecum, ascending colon or hepatic flexure (51% vs 30%, p Z 0.017). No other significant differences were found. Conclusions: 5.5% of all patients diagnosed with CRC had a complete, clearing colonoscopy previously. Such CRCs were more likely to occur in the proximal right colon, but were not associated with the staff physician, fellow participation, or prep quality. Overall survival was not improved for patients despite having a prior clearing colonoscopy.
Bowel obstruction is the presentation form of 10-30% of patients with colorectal malignant tumours. Palliative surgical intervention is associated with hight morbidity and mortality, especially when performed in an emergency situation. Insertion of colorectal stents has been described as a therapeutic alternative for the resolution of colorectal malignant obstruction. Aim: To evaluate the efficacy and safety of colorectal stenting as a palliative therapy or as a ‘‘bridge to surgery’’ procedure for intestinal malignant obstruction. Material and Methods: Retrospective study of 36 consecutive patients (16-female; 20-male) submitted to colorectal stenting between January 1999 and July 2004. Mean age 73 years (range 49 to 90). The stents were inserted as a definitive palliative therapeutic in 34 patients (all with advanced stage disease) and in 2 as a ‘‘bridge to surgery’’. The stents used were the Wallstent and Ultraflex Precision, both from Boston Scientific, inserted under endoscopic and fluoroscopic guidance. The site of obstruction was: rectum in 8 patients, rectosigmoidal transition in 7, sigmoid in 11, descendent colon in 1, ascendent colon in 2 and surgical anasthomosis (recurrent cancer) in 7. A technical success (successful stent placement and deployment) was achived in 83% (30/36). In one patient with obstruction of a tortuous rectosimoid flexure, stenting was not possible. Complications ocurred in 10 patients (28%). These include perforation of the colon (n Z 3); stent migration (n Z 4), with two late migrations, tumor ingrowth (n Z 2) and fecal incontinence (n Z 1). Insertion of a second stent was required in 4 patients to transverse long strictures. In the group that was stented as a ‘‘bridge to surgery’’, after complete staging of the disease, only one needeed subsequent operation and a stoma creation was not required. There was no mortality directed related with the procedure. Mean survival was 107 days (1 to 370 days). Conclusions: Insertion of selfexpanding colorectal stents is a relative safe and effective palliative procedure that can avoid surgical intervention in patients with colorectal obstruction due to tumours in advanced staged disease. It can also be used for preoperative ‘‘bridge to surgery’’ treatment sparing the potencial problems associated with palliative stoma formation.
W1097 Variability in the Diagnosis and Management of Adenoma-Like and Non-Adenoma Like Dalms in Patients with Ulcerative Colitis Francis A. Farraye, Jerome D. Waye, Timothy C. Heeren, Robert D. Odze Recent studies have shown that ulcerative colitis (UC) patients with adenoma-like DALMs (ALD) may be treated adequately by polypectomy and continued surveillance, in contrast to non adenoma-like DALMs (NALD) which are considered an indication for colectomy because of the high association with carcinoma. Since it is difficult pathologically to distinguish between these two types of lesions, it is incumbent upon gastroenterologists (GE) to differentiate ALD from NALD based on their endoscopic appearance. The aims of this study were to determine the ability of GE to distinguish between ALD, NALD and inflammatory polyps (IP) and to evaluate the variation in their management practices for these polyps. Methods: Randomly chosen members of the ASGE within private practice (n Z 12), academic hospital practice (n Z 13) and a group of IBD experts (n Z 13) were asked to answer a series of questions on the diagnosis and management of UCassociated polypoid lesions via an Internet based survey of 13 endoscopic images (ALD Z 5, NALD Z 5, IP Z 3). The GE were asked to categorize each image into one of the 3 diagnostic categories and answer several questions regarding possible management options. Results: ALD, NALD and IP were correctly diagnosed by 75%, 73% and 83% of experts, by 53%, 62% and 61% of academic GE and 56%, 69%, and 61% of private GE, respectively. Experts had significantly higher agreement (Kappa 0.64) than the academic (Kappa 0.36) or private GE (Kappa 0.42) for the diagnosis of polyps (p ! 0.01). Overall, experts had significantly higher agreement than the other GEs for the correct diagnosis of ALD (p Z 0.05), and IP (p Z 0.01), but not NALD (p Z 0.5). Regarding management, expert GE more often biopsy the mucosa around a polypectomy site (93%) compared with academic GE (69%) or private GE (58%), p Z 0.04. Essentially all GE recommend colectomy for ALD with surrounding flat dysplasia. However, for ALD without surrounding flat dysplasia there is significant disagreement among experts and other GE with regard to treatment of those with high-grade dysplasia; more academic and private GE recommend colectomy (expert GE: 20%, academic GE: 62% and private GE: 58%, p Z 0.01). Conclusions: These data suggest that academic and private GE have more difficulty than experts distinguishing between, and managing, ALD in patients with UC. Reproducible objective criteria to separate ALD from NALD, and standardized management guidelines, are needed for GE who treat UC patients.
AB250 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
W1099 Annual Fecal Occult Blood Testing Can Be Safely Suspended for Up To 5 Years After a Negative Colonoscopy in Asymptomatic Average-Risk Patients Steven Finkelstein, Edmund J. Bini Background: In clinical practice, physicians often continue to perform annual fecal occult blood testing (FOBT) in patients who have had a recent negative colonoscopy. The Centers for Disease Control and Prevention (CDC) discourages this practice because it increases the likelihood of false positive results, and they recommend suspending annual FOBT for 5-10 years after a negative total colon exam. However, these recommendations were based on ‘‘expert’’ opinion. The aim of this prospective study was to determine the proportion of patients with a positive FOBTwho had adenomas and cancers on colonoscopy stratified according to duration of time since the last negative colonoscopy. Methods: 1,119 asymptomatic average-risk patients R 50 years of age who were referred for colonoscopy to evaluate a positive FOBT were prospectively identified. A detailed medical history was obtained from all patients prior to colonoscopy, and subjects were stratified by the duration of time since last colonoscopy (never had a colonoscopy, negative colonoscopy O10 years, 5-10 years, or O5 years). The proportion of patients in each category with adenomas of any size, adenomas Z 10 mm, advanced neoplasms (adenomas Z 10 mm or any adenoma, regardless of size, with villous histology, high-grade dysplasia, or cancer), and cancers was assessed. Results: The mean age (68.9 G 9.6 years), sex (95.2% male), and race (48.1% white, 32.1% black, 15.6% Hispanic, and 4.2% other) did not differ between the 4 groups. Colonoscopy was complete to the cecum in 97.1% of patients and was similar in all 4 groups (P Z 0.61). Overall, adenomas of any size were detected in 42.8% of patients, adenomas Z10 mm in 14.7%, advanced neoplasms in 20.7%, and cancers in 7.3%. Conclusions: In asymptomatic average-risk patients who have had a negative colonoscopy within the last 5 years, the prevalence of adenomas is low and no patient was diagnosed with cancer. Although these findings support the CDC recommendations to suspend annual FOBT for up to 5 years after a negative total colon examination, suspending FOBT for up to 10 years may miss potentially curable lesions.
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W1096 Predictive Factors for Colorectal Cancers Occurring in Patients After a Clearing Colonoscopy William D. Farrar, Douglas B. Nelson, John H. Bond, Mandeep S. Sawhney
W1098 Expandable Metal Stent Placement for Malignant Colorectal Obstruction - Report of 36 Consecutive Patients Julieta Fe´lix, Jo~ao Deus, Ricardo Gorj~ao, Eduardo Pires, Paulo Ratilal, Luis Novais
Background: A small but finite number of patients develop colorectal cancer (CRC) despite having a clearing colonoscopy. Aim: To evaluate factors associated with CRCs found after a colonoscopy such as staff physician performing the colonoscopy, trainee participation, poor prep or proximal tumor location. Methods: The Minneapolis VA colon cancer registry was used to identify cases who were found to have CRC between 6 and 66 months of a complete, clearing colonoscopy. Controls were patients diagnosed with CRC on their first colonoscopy. Two controls for every case were selected, matched by the year of cancer diagnosis to the year of each case’s initial colonoscopy. Patients with FAP, HNPCC, IBD or anastomotic cancers were excluded. Factors were compared using the chi-squared test. 5-year overall mortality was calculated using a Kaplan-Meier survival analysis and log-rank test. Results: Out of 813 CRC’s between 1/1/1991 and 8/31/2004, 45 cases were identified (5.5%). The average time between colonoscopies was 34 months (Range: 12-64 months). Compared to 90 controls, CRCs in cases were more likely to be located in the cecum, ascending colon or hepatic flexure (51% vs 30%, p Z 0.017). No other significant differences were found. Conclusions: 5.5% of all patients diagnosed with CRC had a complete, clearing colonoscopy previously. Such CRCs were more likely to occur in the proximal right colon, but were not associated with the staff physician, fellow participation, or prep quality. Overall survival was not improved for patients despite having a prior clearing colonoscopy.
Bowel obstruction is the presentation form of 10-30% of patients with colorectal malignant tumours. Palliative surgical intervention is associated with hight morbidity and mortality, especially when performed in an emergency situation. Insertion of colorectal stents has been described as a therapeutic alternative for the resolution of colorectal malignant obstruction. Aim: To evaluate the efficacy and safety of colorectal stenting as a palliative therapy or as a ‘‘bridge to surgery’’ procedure for intestinal malignant obstruction. Material and Methods: Retrospective study of 36 consecutive patients (16-female; 20-male) submitted to colorectal stenting between January 1999 and July 2004. Mean age 73 years (range 49 to 90). The stents were inserted as a definitive palliative therapeutic in 34 patients (all with advanced stage disease) and in 2 as a ‘‘bridge to surgery’’. The stents used were the Wallstent and Ultraflex Precision, both from Boston Scientific, inserted under endoscopic and fluoroscopic guidance. The site of obstruction was: rectum in 8 patients, rectosigmoidal transition in 7, sigmoid in 11, descendent colon in 1, ascendent colon in 2 and surgical anasthomosis (recurrent cancer) in 7. A technical success (successful stent placement and deployment) was achived in 83% (30/36). In one patient with obstruction of a tortuous rectosimoid flexure, stenting was not possible. Complications ocurred in 10 patients (28%). These include perforation of the colon (n Z 3); stent migration (n Z 4), with two late migrations, tumor ingrowth (n Z 2) and fecal incontinence (n Z 1). Insertion of a second stent was required in 4 patients to transverse long strictures. In the group that was stented as a ‘‘bridge to surgery’’, after complete staging of the disease, only one needeed subsequent operation and a stoma creation was not required. There was no mortality directed related with the procedure. Mean survival was 107 days (1 to 370 days). Conclusions: Insertion of selfexpanding colorectal stents is a relative safe and effective palliative procedure that can avoid surgical intervention in patients with colorectal obstruction due to tumours in advanced staged disease. It can also be used for preoperative ‘‘bridge to surgery’’ treatment sparing the potencial problems associated with palliative stoma formation.
W1097 Variability in the Diagnosis and Management of Adenoma-Like and Non-Adenoma Like Dalms in Patients with Ulcerative Colitis Francis A. Farraye, Jerome D. Waye, Timothy C. Heeren, Robert D. Odze Recent studies have shown that ulcerative colitis (UC) patients with adenoma-like DALMs (ALD) may be treated adequately by polypectomy and continued surveillance, in contrast to non adenoma-like DALMs (NALD) which are considered an indication for colectomy because of the high association with carcinoma. Since it is difficult pathologically to distinguish between these two types of lesions, it is incumbent upon gastroenterologists (GE) to differentiate ALD from NALD based on their endoscopic appearance. The aims of this study were to determine the ability of GE to distinguish between ALD, NALD and inflammatory polyps (IP) and to evaluate the variation in their management practices for these polyps. Methods: Randomly chosen members of the ASGE within private practice (n Z 12), academic hospital practice (n Z 13) and a group of IBD experts (n Z 13) were asked to answer a series of questions on the diagnosis and management of UCassociated polypoid lesions via an Internet based survey of 13 endoscopic images (ALD Z 5, NALD Z 5, IP Z 3). The GE were asked to categorize each image into one of the 3 diagnostic categories and answer several questions regarding possible management options. Results: ALD, NALD and IP were correctly diagnosed by 75%, 73% and 83% of experts, by 53%, 62% and 61% of academic GE and 56%, 69%, and 61% of private GE, respectively. Experts had significantly higher agreement (Kappa 0.64) than the academic (Kappa 0.36) or private GE (Kappa 0.42) for the diagnosis of polyps (p ! 0.01). Overall, experts had significantly higher agreement than the other GEs for the correct diagnosis of ALD (p Z 0.05), and IP (p Z 0.01), but not NALD (p Z 0.5). Regarding management, expert GE more often biopsy the mucosa around a polypectomy site (93%) compared with academic GE (69%) or private GE (58%), p Z 0.04. Essentially all GE recommend colectomy for ALD with surrounding flat dysplasia. However, for ALD without surrounding flat dysplasia there is significant disagreement among experts and other GE with regard to treatment of those with high-grade dysplasia; more academic and private GE recommend colectomy (expert GE: 20%, academic GE: 62% and private GE: 58%, p Z 0.01). Conclusions: These data suggest that academic and private GE have more difficulty than experts distinguishing between, and managing, ALD in patients with UC. Reproducible objective criteria to separate ALD from NALD, and standardized management guidelines, are needed for GE who treat UC patients.
AB250 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
W1099 Annual Fecal Occult Blood Testing Can Be Safely Suspended for Up To 5 Years After a Negative Colonoscopy in Asymptomatic Average-Risk Patients Steven Finkelstein, Edmund J. Bini Background: In clinical practice, physicians often continue to perform annual fecal occult blood testing (FOBT) in patients who have had a recent negative colonoscopy. The Centers for Disease Control and Prevention (CDC) discourages this practice because it increases the likelihood of false positive results, and they recommend suspending annual FOBT for 5-10 years after a negative total colon exam. However, these recommendations were based on ‘‘expert’’ opinion. The aim of this prospective study was to determine the proportion of patients with a positive FOBTwho had adenomas and cancers on colonoscopy stratified according to duration of time since the last negative colonoscopy. Methods: 1,119 asymptomatic average-risk patients R 50 years of age who were referred for colonoscopy to evaluate a positive FOBT were prospectively identified. A detailed medical history was obtained from all patients prior to colonoscopy, and subjects were stratified by the duration of time since last colonoscopy (never had a colonoscopy, negative colonoscopy O10 years, 5-10 years, or O5 years). The proportion of patients in each category with adenomas of any size, adenomas Z 10 mm, advanced neoplasms (adenomas Z 10 mm or any adenoma, regardless of size, with villous histology, high-grade dysplasia, or cancer), and cancers was assessed. Results: The mean age (68.9 G 9.6 years), sex (95.2% male), and race (48.1% white, 32.1% black, 15.6% Hispanic, and 4.2% other) did not differ between the 4 groups. Colonoscopy was complete to the cecum in 97.1% of patients and was similar in all 4 groups (P Z 0.61). Overall, adenomas of any size were detected in 42.8% of patients, adenomas Z10 mm in 14.7%, advanced neoplasms in 20.7%, and cancers in 7.3%. Conclusions: In asymptomatic average-risk patients who have had a negative colonoscopy within the last 5 years, the prevalence of adenomas is low and no patient was diagnosed with cancer. Although these findings support the CDC recommendations to suspend annual FOBT for up to 5 years after a negative total colon examination, suspending FOBT for up to 10 years may miss potentially curable lesions.
www.mosby.com/gie