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Mo1400 Preoperative Colonoscopy Through the Colonic Stent in Patients of Colon Cancer Obstruction
Abstracts
Mo1400 Preoperative Colonoscopy Through the Colonic Stent in Patients of Colon Cancer Obstruction Jin-Hee No*, Jin Su Kim, Chul-Hyun Lim, Eun Jung Kim, Yu Kyung Cho, Kang Moon Lee, Sang Woo Kim, Myung-Gyu Choi, Kyu-Yong Choi, in-Sik Chung Seoul St. Mary’s Hospital, Seoul, Republic of Korea Background: Preoperative complete evaluation of the entire colon in patients with colorectal cancer is important because synchronous cancers can be found. Unfortunately, some patients with colorectal cancer have acute colonic obstruction, making complete colonoscopy impossible. Objective: The aim of our study was to evaluate the feasibility of a preoperative complete colonoscopy after stent insertion (passage of colonoscopy through the stent and examination of entire colon) in patients with malignant colonic obstruction and factors that affect complete colonoscopy. Patients and Methods: From May 2010 to May 2011, patients with acute malignant colonic obstruction were prospectively included in the study after stent ((HANAROSTENT®, diameter 26mm, length 8cm to 16cm, M.I. Tech., Seoul, Korea) insertion. Patients were eligible for the study if they presented with clinical signs and symptoms of intestinal obstruction. Patients with unresectable cancer and incomplete resolution of colonic obstruction, signs of peritonitis, perforation, fever, and sepsis after stent insertion were excluded. After effective stent placement and complete resolution of obstructive symptoms, patients received standard bowel preparation. Preoperative colonoscopy (CF-H260AI [13.2mm outer diameter]; Olympus, Japan) was then performed. After colonoscopy, cecal intubation rate, cecal intubation time, grade of bowel preparation, tumor location, stent location, presence of synchronous polyp or cancer, damage to colonoscope, bleeding and stent migration after colonoscopy were recorded. Results: A total of 45 patients underwent a preoperative colonoscopy. The subject characteristics are listed in table 1. Complete colonoscopy was possible in 27 of 45 patients (60%) and the mean cecal intubation time was 9 min 20 sec. Adenomatous polyps (1 high grade adenoma and 14 low grade adenomas in right colon, 11 low grade adenomas in transverse colon, 4 low grade adenomas in left colon) were found in 17 of 27 patients (62%). All the patients with synchronous lesions underwent snare polypectomy. Factors that affect complete colonoscopy were analyzed. Stent expansion diameter, tumor located in angle (splenic flexure, sigmoiddescending and recto-sigmoid junction), stent placed at angle, significantly affect complete colonoscopy. T and N stage of tumor, previous operation history, stent and tumor length did not affect complete colonoscopy. (Table 2.) No endoscope mechanical damage, bleeding at the stent site and stent migration was detected after colonoscopy procedure. Conclusion: Complete colonoscopy through the stent is not feasible as expected. Tumor at angle, stent placement at angle, extent of stent expansion expanded diameter may affect complete colonoscopy. Table 1. Subjective characteristics (nⴝ45) Male (n, %) Age (mean⫾ SD) BMI (mean ⫾ SD) Site of cancer
Distal T colon Splenic flexure Descending SD junction Sigmoid colon RS junction Rectum
25 (55%) 63.2 ⫾ 13.3 23.2 ⫾ 2.45 1 2 9 1 24 6 2
Cecal intubation (nⴝ27)
Fail (nⴝ18)
P-value
64.5 ⫾ 14.5 14/13 23.3 ⫾ 2.56 9.7 ⫾ 1.98 cm 8/27 (29%) (22/5) (10/8/9) 1 0 7 1 15 (55.6%) 12
61.3 ⫾ 11.4 10/8 23.2 ⫾ 2.45 8.7 ⫾ 1.37cm 2/27 (11%) (13/5) (3/9/6) 02209 (50.0%) 5 0
0.87 0.81 0.74 0.60 0.272 0.489 0.254 0.17
2/27 (7.4%) 7/27 (25.9%) 19.88 ⫾ 2.62 mm
6/18 (33.3%) 10/18 (55.6%) 15.05 ⫾ 3.42 mm
0.045 0.045 0.01
6.20 ⫾ 2.57 cm
Introduction: In Japan and South Korea, endoscopic submucosal dissection (ESD) is routinely used for large superficial neoplastic lesions in the upper GI tract, and recently for high-risk colonic lesions. Western experience in ESD is limited, and no data are available on colorectal ESD learning curve. To assess the learning curves both of rectal and colonic ESD. Methods: Prospective single center study involving a single endoscopist novice in ESD. Pre-study training was: 5 not-supervised and 1 supervised ESD on isolated stomach at the EETC and NCCH, respectively; a 2-week observer period at the NCCH. ESD was performed with the standard technique, with video-colonoscopes and air insufflation. Indications for ESD were: superficial neoplastic lesions ⱖ20mm. Learning curves for rectal and colonic ESD were assessed comparing results of consecutive groups of 5 procedures. Primary outcomes were: en bloc resection rate; operative time for unit (cm2) of resected specimen; perforation rate. Morphologic and pathologic features were analyzed as prognostic variables of en bloc resection. Results: From 2/2009 to 11/2011, 30 rectal-ESD and 25 colonicESDs were performed. colonic-ESD started to be performed 1 year later (after 15 rectal-ESDs). Median lesion size was 25mm in the rectum and 30mm in the colon. Morphology was LST in 90% of rectal and 84% of colonic cases. Learning curve of rectal-ESDs assessed on 6 experience groups showed: 1) a steady en bloc resection rate ⱖ80% after 20 procedures; 2) a significant decrease of the operative time per cm2 decreased significantly after 20 procedures (from 45 min to 16 min; P⫽0.0079); 3) perforation rate was 20% within the first 10 cases. Learning curve of colon-ESD assessed on 5 experience groups showed: 1) an increase of en bloc resection rate from 20% to 60% after the first 10 procedures without changes in the following 15 cases; 2) a significant decrease of the operative time per cm2 after 20 procedures (from 65 to 8 min; P⫽0.031); 3) perforation rate was 20% within the first 10 cases. Univariate analysis for ESD en bloc resection in either the rectum or colon did not identify any significant variable for prognosis. However when rectal and colonic lesions were considered as a whole, colon location was the only independent negative prognostic variable (OR 0.28; 95%CI 0.09-0.89). Conclusion: Rectal-ESD is feasible and safe even in the early beginning of the experience and a steady 80% en bloc resection rate and significantly lower operative times are achieved after 20 procedures which coincedes with the end of the steep phase of the learning curve. Colonic-ESD is much more complex and risky than r-ESD with a lower en bloc resection rate and longer operative time. LEARNING CURVE (n. ESDs) 1-5
Table 2. Factors affecting complete colonoscopy
Age (yr, mean ⫾ SD) Gender (M/F) BMI (mean ⫾ SD) Stent length (mean ⫾ SD) Abdomen operation (Y/N) T stage (T3/T4) N stage (N0/N1/N2) Tumor location Distal T colon Splenic flexure Descending SD junction Sigmoid colon RS junction Rectum Tumor at angle* Stent placement at angle* Stent expansion diameter(mean⫾SD) Tumor length (mean⫾SD)
Mo1401 Prospective Study for the Learning Curves of Endoscopic Submucosal Dissection (ESD) in the Rectum and Colon Federico Iacopini*1, Patrizia Rigato2, Antonino Bella3, Takuji Gotoda4, Yutaka Saito5, Guido Costamagna6, Walter Elisei1, Cristina Grossi1, Agostino Scozzarro1 1 Gastroenterology and Endoscopy Unit, S.Giuseppe Hospital, Albano L, Rome, Italy, Albano L., Rome, Italy; 2Pathology Unit, Ospedale S. Giuseppe, Marino, Rome, Italy; 3C.N.E.S.P.S., Istituto Superiore di Sanità, Rome, Italy; 4Gastroenterology & Hepatology, National Center for Global Health and Medicine, Tokyo, Japan; 5Endoscopy Unit, National Cancer Center Hospital, Tokyo, Japan; 6Digestive Surgical Endoscopy Unit, Policlinico Gemelli, and European Endoscopic Training Center, Università Cattolica, Rome, Italy
6.06 ⫾ 2.45 cm
*Angle: Splenic flexure, Sigmoid-descending junction, Recto-sigmoid junction.
0.9
6-10
11-15
16-20
21-25
26-30
Pⴝ
RECTUM En bloc resection, 3 (60) 4 (80) 3 (60) 5 (100) 4 (80) 4 (80) n.s. n. (%) R0 resection, n. (%) 1 (20) 4 (80) 2 (40) 3 (60) 4 (80) 4 (80) n.s. Time (min) per cm2 45 (31-108) 55 (30-130) 27 (16-74) 43 (13-77) 16 (10-24) 12 (9-37) 0.021 COLON En bloc resection, 1 (20) 2 (40) 3 (60) 3 (60) 3 (60) n.s. n. (%) R0 resection, n. (%) 1 (20) 1 (20) 2 (40) 2 (40) 3 (60) n.s. Time (min) per cm2 65 (12-339) 53 (18-126) 22 (9-29) 23 (2-36) 8 (5-22) 0.017
Mo1402 Failure to Recognize Serrated Polyposis Syndrome in a Cohort With Large Sessile Colorectal Polyps Krishna C. Vemulapalli*, Douglas K. Rex Department of Medicine, Indiana University Health, Indianapolis, IN Background: Serrated Polyposis Syndrome (SPS) is a rare condition of multiple serrated colorectal polyps. Colorectal cancer risk is increased in SPS. We determined the prevalence of SPS in a cohort of patients with large (⬎ 2cm) sessile colorectal polyps, and the rate at which the diagnosis was made by the clinicians. Methods: Review of a patient care database describing 529 consecutive patients referred to a single endoscopist for endoscopic resection of a sessile colorectal polyp ⬎ 2cm in size. The 2010 World Health Organization criteria
AB413 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org
Mo1400 Preoperative Colonoscopy Through the Colonic Stent in Patients of Colon Cancer Obstruction Jin-Hee No*, Jin Su Kim, Chul-Hyun Lim, Eun Jung Kim, Yu Kyung Cho, Kang Moon Lee, Sang Woo Kim, Myung-Gyu Choi, Kyu-Yong Choi, in-Sik Chung Seoul St. Mary’s Hospital, Seoul, Republic of Korea Background: Preoperative complete evaluation of the entire colon in patients with colorectal cancer is important because synchronous cancers can be found. Unfortunately, some patients with colorectal cancer have acute colonic obstruction, making complete colonoscopy impossible. Objective: The aim of our study was to evaluate the feasibility of a preoperative complete colonoscopy after stent insertion (passage of colonoscopy through the stent and examination of entire colon) in patients with malignant colonic obstruction and factors that affect complete colonoscopy. Patients and Methods: From May 2010 to May 2011, patients with acute malignant colonic obstruction were prospectively included in the study after stent ((HANAROSTENT®, diameter 26mm, length 8cm to 16cm, M.I. Tech., Seoul, Korea) insertion. Patients were eligible for the study if they presented with clinical signs and symptoms of intestinal obstruction. Patients with unresectable cancer and incomplete resolution of colonic obstruction, signs of peritonitis, perforation, fever, and sepsis after stent insertion were excluded. After effective stent placement and complete resolution of obstructive symptoms, patients received standard bowel preparation. Preoperative colonoscopy (CF-H260AI [13.2mm outer diameter]; Olympus, Japan) was then performed. After colonoscopy, cecal intubation rate, cecal intubation time, grade of bowel preparation, tumor location, stent location, presence of synchronous polyp or cancer, damage to colonoscope, bleeding and stent migration after colonoscopy were recorded. Results: A total of 45 patients underwent a preoperative colonoscopy. The subject characteristics are listed in table 1. Complete colonoscopy was possible in 27 of 45 patients (60%) and the mean cecal intubation time was 9 min 20 sec. Adenomatous polyps (1 high grade adenoma and 14 low grade adenomas in right colon, 11 low grade adenomas in transverse colon, 4 low grade adenomas in left colon) were found in 17 of 27 patients (62%). All the patients with synchronous lesions underwent snare polypectomy. Factors that affect complete colonoscopy were analyzed. Stent expansion diameter, tumor located in angle (splenic flexure, sigmoiddescending and recto-sigmoid junction), stent placed at angle, significantly affect complete colonoscopy. T and N stage of tumor, previous operation history, stent and tumor length did not affect complete colonoscopy. (Table 2.) No endoscope mechanical damage, bleeding at the stent site and stent migration was detected after colonoscopy procedure. Conclusion: Complete colonoscopy through the stent is not feasible as expected. Tumor at angle, stent placement at angle, extent of stent expansion expanded diameter may affect complete colonoscopy. Table 1. Subjective characteristics (nⴝ45) Male (n, %) Age (mean⫾ SD) BMI (mean ⫾ SD) Site of cancer
Distal T colon Splenic flexure Descending SD junction Sigmoid colon RS junction Rectum
25 (55%) 63.2 ⫾ 13.3 23.2 ⫾ 2.45 1 2 9 1 24 6 2
Cecal intubation (nⴝ27)
Fail (nⴝ18)
P-value
64.5 ⫾ 14.5 14/13 23.3 ⫾ 2.56 9.7 ⫾ 1.98 cm 8/27 (29%) (22/5) (10/8/9) 1 0 7 1 15 (55.6%) 12
61.3 ⫾ 11.4 10/8 23.2 ⫾ 2.45 8.7 ⫾ 1.37cm 2/27 (11%) (13/5) (3/9/6) 02209 (50.0%) 5 0
0.87 0.81 0.74 0.60 0.272 0.489 0.254 0.17
2/27 (7.4%) 7/27 (25.9%) 19.88 ⫾ 2.62 mm
6/18 (33.3%) 10/18 (55.6%) 15.05 ⫾ 3.42 mm
0.045 0.045 0.01
6.20 ⫾ 2.57 cm
Introduction: In Japan and South Korea, endoscopic submucosal dissection (ESD) is routinely used for large superficial neoplastic lesions in the upper GI tract, and recently for high-risk colonic lesions. Western experience in ESD is limited, and no data are available on colorectal ESD learning curve. To assess the learning curves both of rectal and colonic ESD. Methods: Prospective single center study involving a single endoscopist novice in ESD. Pre-study training was: 5 not-supervised and 1 supervised ESD on isolated stomach at the EETC and NCCH, respectively; a 2-week observer period at the NCCH. ESD was performed with the standard technique, with video-colonoscopes and air insufflation. Indications for ESD were: superficial neoplastic lesions ⱖ20mm. Learning curves for rectal and colonic ESD were assessed comparing results of consecutive groups of 5 procedures. Primary outcomes were: en bloc resection rate; operative time for unit (cm2) of resected specimen; perforation rate. Morphologic and pathologic features were analyzed as prognostic variables of en bloc resection. Results: From 2/2009 to 11/2011, 30 rectal-ESD and 25 colonicESDs were performed. colonic-ESD started to be performed 1 year later (after 15 rectal-ESDs). Median lesion size was 25mm in the rectum and 30mm in the colon. Morphology was LST in 90% of rectal and 84% of colonic cases. Learning curve of rectal-ESDs assessed on 6 experience groups showed: 1) a steady en bloc resection rate ⱖ80% after 20 procedures; 2) a significant decrease of the operative time per cm2 decreased significantly after 20 procedures (from 45 min to 16 min; P⫽0.0079); 3) perforation rate was 20% within the first 10 cases. Learning curve of colon-ESD assessed on 5 experience groups showed: 1) an increase of en bloc resection rate from 20% to 60% after the first 10 procedures without changes in the following 15 cases; 2) a significant decrease of the operative time per cm2 after 20 procedures (from 65 to 8 min; P⫽0.031); 3) perforation rate was 20% within the first 10 cases. Univariate analysis for ESD en bloc resection in either the rectum or colon did not identify any significant variable for prognosis. However when rectal and colonic lesions were considered as a whole, colon location was the only independent negative prognostic variable (OR 0.28; 95%CI 0.09-0.89). Conclusion: Rectal-ESD is feasible and safe even in the early beginning of the experience and a steady 80% en bloc resection rate and significantly lower operative times are achieved after 20 procedures which coincedes with the end of the steep phase of the learning curve. Colonic-ESD is much more complex and risky than r-ESD with a lower en bloc resection rate and longer operative time. LEARNING CURVE (n. ESDs) 1-5
Table 2. Factors affecting complete colonoscopy
Age (yr, mean ⫾ SD) Gender (M/F) BMI (mean ⫾ SD) Stent length (mean ⫾ SD) Abdomen operation (Y/N) T stage (T3/T4) N stage (N0/N1/N2) Tumor location Distal T colon Splenic flexure Descending SD junction Sigmoid colon RS junction Rectum Tumor at angle* Stent placement at angle* Stent expansion diameter(mean⫾SD) Tumor length (mean⫾SD)
Mo1401 Prospective Study for the Learning Curves of Endoscopic Submucosal Dissection (ESD) in the Rectum and Colon Federico Iacopini*1, Patrizia Rigato2, Antonino Bella3, Takuji Gotoda4, Yutaka Saito5, Guido Costamagna6, Walter Elisei1, Cristina Grossi1, Agostino Scozzarro1 1 Gastroenterology and Endoscopy Unit, S.Giuseppe Hospital, Albano L, Rome, Italy, Albano L., Rome, Italy; 2Pathology Unit, Ospedale S. Giuseppe, Marino, Rome, Italy; 3C.N.E.S.P.S., Istituto Superiore di Sanità, Rome, Italy; 4Gastroenterology & Hepatology, National Center for Global Health and Medicine, Tokyo, Japan; 5Endoscopy Unit, National Cancer Center Hospital, Tokyo, Japan; 6Digestive Surgical Endoscopy Unit, Policlinico Gemelli, and European Endoscopic Training Center, Università Cattolica, Rome, Italy
6.06 ⫾ 2.45 cm
*Angle: Splenic flexure, Sigmoid-descending junction, Recto-sigmoid junction.
0.9
6-10
11-15
16-20
21-25
26-30
Pⴝ
RECTUM En bloc resection, 3 (60) 4 (80) 3 (60) 5 (100) 4 (80) 4 (80) n.s. n. (%) R0 resection, n. (%) 1 (20) 4 (80) 2 (40) 3 (60) 4 (80) 4 (80) n.s. Time (min) per cm2 45 (31-108) 55 (30-130) 27 (16-74) 43 (13-77) 16 (10-24) 12 (9-37) 0.021 COLON En bloc resection, 1 (20) 2 (40) 3 (60) 3 (60) 3 (60) n.s. n. (%) R0 resection, n. (%) 1 (20) 1 (20) 2 (40) 2 (40) 3 (60) n.s. Time (min) per cm2 65 (12-339) 53 (18-126) 22 (9-29) 23 (2-36) 8 (5-22) 0.017
Mo1402 Failure to Recognize Serrated Polyposis Syndrome in a Cohort With Large Sessile Colorectal Polyps Krishna C. Vemulapalli*, Douglas K. Rex Department of Medicine, Indiana University Health, Indianapolis, IN Background: Serrated Polyposis Syndrome (SPS) is a rare condition of multiple serrated colorectal polyps. Colorectal cancer risk is increased in SPS. We determined the prevalence of SPS in a cohort of patients with large (⬎ 2cm) sessile colorectal polyps, and the rate at which the diagnosis was made by the clinicians. Methods: Review of a patient care database describing 529 consecutive patients referred to a single endoscopist for endoscopic resection of a sessile colorectal polyp ⬎ 2cm in size. The 2010 World Health Organization criteria
AB413 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org