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Polyps With Cytological Dysplasia by NBI Observation
Abstracts
Sa1427 Combined Water Exchange and CAP-Assisted Colonoscopy Optimizes Insertion Pain Control and Completion of Colonoscopy Without Pain in Unsedated Male Patients With High Yield of Proximal Colon Adenomas Felix W. Leung*1, Yu-Hsi Hsieh3,4, Joseph W. Leung2,5, James Sul6, Andrew W. Yen2,5 1 Gastroenterology, VA Sepulveda Ambulatory Care Center, VAGLAHS and David Geffen School of Medicine at UCLA, North Hills, CA; 2Gastroenterology, Sacramento VAMC, Mather, CA; 3Gastroenterology, Buddhist Dalin Tzu Chi General Hospital, Chia-Yi, Taiwan; 4Gastroenterology, Buddhist Tzu Chi University, School of Medicine, Hualien, Taiwan; 5Gastroenterology, University of California at Davis Medical Center, Sacramento, CA; 6 Gastroenterology, West Los Angeles VAMC, Los Angeles, CA Background: Successful unsedated colonoscopy obviates sedation complications, procedural monitoring, recovery observation, post-procedure activity restriction and recovery time burdens (GIE 2009;69:1354). It is a/an unique choice of educated professionals (GIE 1999;49:554, JCG 2005;39:516), practical alternative in patients with paradoxical agitation (AJG 2008;103:1578), effective approach to manage no show due to no escort (JIG 2014;4:91), option in willing patients without escorts (GIE 2002;55:307) or with contraindications for sedation (WJGE 2010;2:81). Limiting the success of cecal intubation without sedation is intolerable real-time maximum insertion pain (RTMIP), a validated measure (GIE 2010;72:693) that correlated significantly with, but uniformly higher than, recalled pain recorded by unbiased observer after colonoscopy. Sedation overcomes limitation of intolerable (high) insertion pain; but when extended to all patients, costs and avoidable side-effects are incurred. Investigators worldwide reported techniques to minimize discomfort in unsedated patients (DDAS 2008;53:1462). Insertion water exchange (WE) overcomes RTMIP-related cecal intubation failures of usual air insufflation (AI) (w20%) by significantly reducing RTMIP, and increases successful completion to O95%, with high patient satisfaction and willingness to repeat without sedation (GIE 2010;72:693). Interestingly, minimal sedation also reduces RTMIP in patients examined with WE, implying that further reduction of RTMIP of WE may be feasible. Sporadic reports suggested cap-assisted colonoscopy (CAC) produced less insertion pain in patients examined by usual AI. The impact of WE combined with CAC on RTMIP in unsedated male patients is unknown. Aim: We review our pilot experience with combined water exchange and cap-assisted colonoscopy (WECAC) in unsedated male patients. Comparison with historical male and mixed gender cohorts examined by WE or CAC alone is used to test the hypothesis that WECAC produces the lowest RTMIP, permitting a high proportion to complete unsedated colonoscopy without pain. Method: 5 colonoscopists with experience in WE at 3 sites performed WECAC. Validated scores of RTMIP (0Znone, 10Zmost severe) were recorded. The mean (SD) of RTMIP score was compared with those of historical cohorts. Results: In 72 unsedated males, mean RTMIP of WECAC is significantly lower than those of historical unsedated cohorts examined by WE or CAC alone (Table 1: 1 vs. 2-6), and indistinguishable from those with minimal sedation added (Table 1: 1 vs. 7,8). WECAC shows a high proportion with painless insertion (47%) and a high proximal colon adenoma detection rate (ADR) (45%) (Table 2). Conclusion: This performance improvement study in unsedated male patients shows WECAC optimizes insertion pain control and completion of colonoscopy without pain and with high proximal colon ADR. Table 1. Comparison of real-time maximum insertion pain (RTMIP)
Techniques
References
1
WECAC
Current pilot study
2
WE
3 4 5
WE WE CAC
6
CAC
7
CAC
Leung F, GIE 2010;72:693 Leung J, JIG 2013;3:7 Luo, GIE 2013;77:767 Choi, JKSC 2010; 26:116 Shida, Surg Endosc 2008;22:2654 Dai, JDD 2010;11:364
8
WE
Hsieh, AJG 2014; 109:1390
Sedation
RTMIP mean (SD)*
USATaiwan USA
Unsedated
1.4 (1.7)
Unsedated
3.6 (2.1)
0.0001
USA China Korea
Unsedated Unsedated Unsedated
3 (2.8) 2.1 (0.9) 2.48 (3.2) Unsedated 2.9 (4.1) ** Minimal*** 1.44 (1.6) Minimal**** 1.4 (2.4)
0.0001 0.0065 0.0091
Study Sites
Japan China Taiwan
p (vs. WECAC)
0.0044 0.8878 1.0000
Table 2. Demographic variables & procedural outcomes Techniques
Cecal intubation***
ADR (%)
Rate (%)
n
Age
BMI
Overall
1 2 3 4
WECAC WE WE WE
72* 42* 50* 55**
30 (5) 30 (7) 22 (3)
20 (13) 34 (3) 13 (7) 12 (4)
97.2 97.6 96 92.7
56 36 54 26****
5
CAC
114**
23 (3)
5 (3)
100
28
6 7 8
CAC CAC WE
82** 65** 90**
62 (9) 66 (9) 61 (7) 56 (11) 46 (11) 63 ( ) 51 ( ) 57 (10)
97.6
25 (3)
5() 6 (3) 17 (6)
Time
Proximal
92.2
16**** 57
Painless insertion (%)
45 17 40 11****
47 7 28
32
61
Data are frequency count, mean (SD) and percent (%) of total. Blank cellZdata not listed. ADR, adenoma detection rate; age in years; BMI, body mass index in kg/m2; cecal intubation time in min. *all male; **mixed gender with male & female; ***Successful based on assigned method. ****Polyp detection rate.
Sa1428 The Endoscopic Differentiation Features of Sessile Serrated Adenoma/ Polyps With Cytological Dysplasia by NBI Observation Shoichi Saito*1, Masahiro Ikegami2, Hiroko Inomata1, Daisuke Ide1, Naoto Tamai1, Tomohiro Kato1, Hisao Tajiri1 1 Endoscopy, The JIkei University School of Medicine, Tokyo, Japan; 2 Pathology, The Jikei University School of Medicine, Tokyo, Japan Introduction: We have already reported about the endoscopic features using image enhanced endoscopy (IEE) concerning about sessile serrated leisons. According to WHO classification, sessile serrated lesions are divided into three categories. One is hyperplastic polyps, the other is traditional serrated adenomas and another is sessile serrated adenoma/ polyps (SSA/Ps). However, SSA/Ps are divided into two subtypes with or without cytological dysplasia in accordance with the dysplastic changes. Therefore, it is confused whether SSA/Ps have dysplastic changes or not, because of the usage the word “adenoma” in SSA/P. In this study, we clarified the endoscopic features by NBI observation about the findings of SSA/Ps involved high grade dysplastic changes including submucosal (SM) invasive cancers. Patients and Methods: Seventy-three SSA/Ps, which are diagnosed according to the WHO criteria were examined before the treatment. These lesions were checked and made by stereoscopy after the resection and diagnosed by two pathologists who are specialized in gastrointestinal tract with using immunohistochemical staining. In this study, CF: H260AZI or FH260AZI scope with Lucera Elite System were used (Olympus Medical Science Tokyo, Japan). Results: Seventy three lesions enrolled as SSA/P and examined in this study. And also eight lesions were contained typical high grade dysplasia (12.3%). Especially, 4 lesions (6.2%) were invaded into SM layer in among 8 lesions. The mean size of SSA/Ps without cytological dysplasia was 18.1mm. In contrast, that of SSA/Ps with cytological dysplasia was 21.0mm. By the conventional observation, mucus cap is adhered with the surface on entire polyps in all 73 lesions of SSA/Ps except for cytological dysplastic part. However, in localized dysplastic part it was possible to diagnose as the cytological dysplasia before the treatment (8 cases). In NBI observation, it was shown to type II-dilatation pit pattern with red cap sign in all lesions. In contrast, the cytological dysplastic parts were similar capillary and surface pattern to conventional tubular adenoma (8 cases). In SM invasive part, those findings were strongly indicated to invasion deeply by NBI findings in all cases (4 cases). From the findings of MIB-1 (ki-67) and p53 immunohistochemical staining, highly cytological dysplasia in SM cancers were shown to different pattern with SSA/P without cytological dysplasia. Discussion: It concluded that it is possible to differentiate between SSA/P lesion with and without cytological dysplasia by using NBI before the treatment. And also the findings in SM cancers was clarified the invasive portion by magnifying observation. Therefore, it is recommended to use the observation by NBI magnification for SSA/P with cytological dysplasia, especially SM invasion in addition to conventional observation.
1Zpilot study; 2-6Zhistorical unsedated cohorts; 7,8Zhistorical minimal sedation cohorts. CAC, cap-assisted colonoscopy; WE, water exchange (water infusion without air insufflation during insertion; infused water is removed mainly during insertion); WECAC, combined water exchange and cap-assisted colonoscopy. *real-time maximum insertion pain (RTMIP): 0Zno pain; 10Zmost severe pain; **assumptions, median used as mean, SD derived from range (0.5-6/1.35)Z4.1; ***diazepam 10 mg & scopolamine 10 mg IM; ****meperidine 25 mg IM.
www.giejournal.org
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB211
Sa1427 Combined Water Exchange and CAP-Assisted Colonoscopy Optimizes Insertion Pain Control and Completion of Colonoscopy Without Pain in Unsedated Male Patients With High Yield of Proximal Colon Adenomas Felix W. Leung*1, Yu-Hsi Hsieh3,4, Joseph W. Leung2,5, James Sul6, Andrew W. Yen2,5 1 Gastroenterology, VA Sepulveda Ambulatory Care Center, VAGLAHS and David Geffen School of Medicine at UCLA, North Hills, CA; 2Gastroenterology, Sacramento VAMC, Mather, CA; 3Gastroenterology, Buddhist Dalin Tzu Chi General Hospital, Chia-Yi, Taiwan; 4Gastroenterology, Buddhist Tzu Chi University, School of Medicine, Hualien, Taiwan; 5Gastroenterology, University of California at Davis Medical Center, Sacramento, CA; 6 Gastroenterology, West Los Angeles VAMC, Los Angeles, CA Background: Successful unsedated colonoscopy obviates sedation complications, procedural monitoring, recovery observation, post-procedure activity restriction and recovery time burdens (GIE 2009;69:1354). It is a/an unique choice of educated professionals (GIE 1999;49:554, JCG 2005;39:516), practical alternative in patients with paradoxical agitation (AJG 2008;103:1578), effective approach to manage no show due to no escort (JIG 2014;4:91), option in willing patients without escorts (GIE 2002;55:307) or with contraindications for sedation (WJGE 2010;2:81). Limiting the success of cecal intubation without sedation is intolerable real-time maximum insertion pain (RTMIP), a validated measure (GIE 2010;72:693) that correlated significantly with, but uniformly higher than, recalled pain recorded by unbiased observer after colonoscopy. Sedation overcomes limitation of intolerable (high) insertion pain; but when extended to all patients, costs and avoidable side-effects are incurred. Investigators worldwide reported techniques to minimize discomfort in unsedated patients (DDAS 2008;53:1462). Insertion water exchange (WE) overcomes RTMIP-related cecal intubation failures of usual air insufflation (AI) (w20%) by significantly reducing RTMIP, and increases successful completion to O95%, with high patient satisfaction and willingness to repeat without sedation (GIE 2010;72:693). Interestingly, minimal sedation also reduces RTMIP in patients examined with WE, implying that further reduction of RTMIP of WE may be feasible. Sporadic reports suggested cap-assisted colonoscopy (CAC) produced less insertion pain in patients examined by usual AI. The impact of WE combined with CAC on RTMIP in unsedated male patients is unknown. Aim: We review our pilot experience with combined water exchange and cap-assisted colonoscopy (WECAC) in unsedated male patients. Comparison with historical male and mixed gender cohorts examined by WE or CAC alone is used to test the hypothesis that WECAC produces the lowest RTMIP, permitting a high proportion to complete unsedated colonoscopy without pain. Method: 5 colonoscopists with experience in WE at 3 sites performed WECAC. Validated scores of RTMIP (0Znone, 10Zmost severe) were recorded. The mean (SD) of RTMIP score was compared with those of historical cohorts. Results: In 72 unsedated males, mean RTMIP of WECAC is significantly lower than those of historical unsedated cohorts examined by WE or CAC alone (Table 1: 1 vs. 2-6), and indistinguishable from those with minimal sedation added (Table 1: 1 vs. 7,8). WECAC shows a high proportion with painless insertion (47%) and a high proximal colon adenoma detection rate (ADR) (45%) (Table 2). Conclusion: This performance improvement study in unsedated male patients shows WECAC optimizes insertion pain control and completion of colonoscopy without pain and with high proximal colon ADR. Table 1. Comparison of real-time maximum insertion pain (RTMIP)
Techniques
References
1
WECAC
Current pilot study
2
WE
3 4 5
WE WE CAC
6
CAC
7
CAC
Leung F, GIE 2010;72:693 Leung J, JIG 2013;3:7 Luo, GIE 2013;77:767 Choi, JKSC 2010; 26:116 Shida, Surg Endosc 2008;22:2654 Dai, JDD 2010;11:364
8
WE
Hsieh, AJG 2014; 109:1390
Sedation
RTMIP mean (SD)*
USATaiwan USA
Unsedated
1.4 (1.7)
Unsedated
3.6 (2.1)
0.0001
USA China Korea
Unsedated Unsedated Unsedated
3 (2.8) 2.1 (0.9) 2.48 (3.2) Unsedated 2.9 (4.1) ** Minimal*** 1.44 (1.6) Minimal**** 1.4 (2.4)
0.0001 0.0065 0.0091
Study Sites
Japan China Taiwan
p (vs. WECAC)
0.0044 0.8878 1.0000
Table 2. Demographic variables & procedural outcomes Techniques
Cecal intubation***
ADR (%)
Rate (%)
n
Age
BMI
Overall
1 2 3 4
WECAC WE WE WE
72* 42* 50* 55**
30 (5) 30 (7) 22 (3)
20 (13) 34 (3) 13 (7) 12 (4)
97.2 97.6 96 92.7
56 36 54 26****
5
CAC
114**
23 (3)
5 (3)
100
28
6 7 8
CAC CAC WE
82** 65** 90**
62 (9) 66 (9) 61 (7) 56 (11) 46 (11) 63 ( ) 51 ( ) 57 (10)
97.6
25 (3)
5() 6 (3) 17 (6)
Time
Proximal
92.2
16**** 57
Painless insertion (%)
45 17 40 11****
47 7 28
32
61
Data are frequency count, mean (SD) and percent (%) of total. Blank cellZdata not listed. ADR, adenoma detection rate; age in years; BMI, body mass index in kg/m2; cecal intubation time in min. *all male; **mixed gender with male & female; ***Successful based on assigned method. ****Polyp detection rate.
Sa1428 The Endoscopic Differentiation Features of Sessile Serrated Adenoma/ Polyps With Cytological Dysplasia by NBI Observation Shoichi Saito*1, Masahiro Ikegami2, Hiroko Inomata1, Daisuke Ide1, Naoto Tamai1, Tomohiro Kato1, Hisao Tajiri1 1 Endoscopy, The JIkei University School of Medicine, Tokyo, Japan; 2 Pathology, The Jikei University School of Medicine, Tokyo, Japan Introduction: We have already reported about the endoscopic features using image enhanced endoscopy (IEE) concerning about sessile serrated leisons. According to WHO classification, sessile serrated lesions are divided into three categories. One is hyperplastic polyps, the other is traditional serrated adenomas and another is sessile serrated adenoma/ polyps (SSA/Ps). However, SSA/Ps are divided into two subtypes with or without cytological dysplasia in accordance with the dysplastic changes. Therefore, it is confused whether SSA/Ps have dysplastic changes or not, because of the usage the word “adenoma” in SSA/P. In this study, we clarified the endoscopic features by NBI observation about the findings of SSA/Ps involved high grade dysplastic changes including submucosal (SM) invasive cancers. Patients and Methods: Seventy-three SSA/Ps, which are diagnosed according to the WHO criteria were examined before the treatment. These lesions were checked and made by stereoscopy after the resection and diagnosed by two pathologists who are specialized in gastrointestinal tract with using immunohistochemical staining. In this study, CF: H260AZI or FH260AZI scope with Lucera Elite System were used (Olympus Medical Science Tokyo, Japan). Results: Seventy three lesions enrolled as SSA/P and examined in this study. And also eight lesions were contained typical high grade dysplasia (12.3%). Especially, 4 lesions (6.2%) were invaded into SM layer in among 8 lesions. The mean size of SSA/Ps without cytological dysplasia was 18.1mm. In contrast, that of SSA/Ps with cytological dysplasia was 21.0mm. By the conventional observation, mucus cap is adhered with the surface on entire polyps in all 73 lesions of SSA/Ps except for cytological dysplastic part. However, in localized dysplastic part it was possible to diagnose as the cytological dysplasia before the treatment (8 cases). In NBI observation, it was shown to type II-dilatation pit pattern with red cap sign in all lesions. In contrast, the cytological dysplastic parts were similar capillary and surface pattern to conventional tubular adenoma (8 cases). In SM invasive part, those findings were strongly indicated to invasion deeply by NBI findings in all cases (4 cases). From the findings of MIB-1 (ki-67) and p53 immunohistochemical staining, highly cytological dysplasia in SM cancers were shown to different pattern with SSA/P without cytological dysplasia. Discussion: It concluded that it is possible to differentiate between SSA/P lesion with and without cytological dysplasia by using NBI before the treatment. And also the findings in SM cancers was clarified the invasive portion by magnifying observation. Therefore, it is recommended to use the observation by NBI magnification for SSA/P with cytological dysplasia, especially SM invasion in addition to conventional observation.
1Zpilot study; 2-6Zhistorical unsedated cohorts; 7,8Zhistorical minimal sedation cohorts. CAC, cap-assisted colonoscopy; WE, water exchange (water infusion without air insufflation during insertion; infused water is removed mainly during insertion); WECAC, combined water exchange and cap-assisted colonoscopy. *real-time maximum insertion pain (RTMIP): 0Zno pain; 10Zmost severe pain; **assumptions, median used as mean, SD derived from range (0.5-6/1.35)Z4.1; ***diazepam 10 mg & scopolamine 10 mg IM; ****meperidine 25 mg IM.
www.giejournal.org
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB211