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Sa1532 Endoscopic Resection of Giant Colonic Polyps - Size Matters!
Abstracts
ESD p-EMR (n[ 66) (n[ 39)
p
OR (CI 95%)
Time O 180 min % 180 min Size O 30 mm
25 (51) 24 (49) 41 (73.2) 15 (26.8)
0.02
2.62 (1.16 - 5.92)
18 (40.9) 26 (59.1)
!0.0001
% 30
48 (78.7) 13 (21.3)
5.33 (2.26 12.58)
Sa1532 Endoscopic Resection of Giant Colonic Polyps - Size Matters! Rupam Bhattacharyya*, Fergus Chedgy, Gaius R. Longcroft-Wheaton, Pradeep Bhandari Portsmouth Hospitals NHS Trust, Cosham, Portsmouth, United Kingdom Introduction: Colonic polyps sized 50mm and above are traditionally treated by surgical resection. Endoscopic resection has now become increasingly common as the expertise of western endoscopists improves. There is very little published literature on endoscopic resection of these giant polyps. Aims: To evaluate the feasibility, safety and efficacy of endoscopic resection of giant polyps R50mm in size. Methods: Prospective cohort study. All patients who underwent endoscopic resection of colonic polyps R50mm from 2007-2013 were prospectively entered into a database. We excluded all polyps with fibrosis related to previous intervention. All patients were tertiary referrals from experienced gastroenterologists. All procedures were performed by a single experienced endoscopist. Results: NZ124 polyps in 122 patients. Mean polyp sizeZ71mm. Range 50-170mm. 27(22%) in right colon and 97 (78%) in left colon. M:F ratio 1.1:1. All polyps were resected in a piecemeal fashion. The mean procedure time was 120 minutes (range 90 to 240).The complication rate was 11/124(8.9%). All these patients required inpatient stay. There were 9 bleeds (3 immediate and 6 delayed), 1 post polypectomy syndrome and 1 case of split muscle fibres (clipped endoscopically). 1 case of immediate bleeding required surgery to control the bleeding. All the others were managed conservatively. 4 of the 9 bleeds required blood transfusion. The complication rate was independent of polyp size, resection technique or site of the lesion. Follow up data was available for 90 polyps. The recurrence rate was 21/90(23.3%). Of the 21 recurrences, 16/21(76%) patients achieved complete clearance with a further 1 to 2 endoscopic procedures. The recurrence rate was significantly dependent on polyp size and was not dependent on the resection technique or the site of the lesion. Recurrence gradually increased with an increase in polyp size up to 70mm. Recurrence was seen in 3/34(8.8%) polyps %55mm, in 7/54(12.9%) polyps %60mm and in 9/63(14.2%) polyps % 70mm. However, in polyps O70mm, the recurrence rate greatly increased to 12/ 27(44%) (pZ0.002). Conclusion: It is safe and feasible to endoscopically resect polyps 50-170mm in size. Recurrence is significantly dependent on polyp size. Giant polyps resected endoscopically have a significant recurrence rate. The majority of these can be cleared by further endoscopic procedures. However, we believe that the recurrence rate in polyps above 70mm is very high and surgery should be considered in these cases. Complication rates are independent of size. Table 1. Effect of increasing polyp size on recurrence Size Recurrence 21/90 (23.3%)
%55mm 3/34 (8.8%)
%60mm 7/54 (12.9%)
%70mm O70mm 9/63 (14.2%) 12/27 (44.4%) pZ0.002
Sa1533 Current Issues and Future Perspective of Gastroduodenal Metal Stent Placement for Malignant GOO: Multicenter Experience Hideki Kamada*1,2, Hirofumi Kawamoto3,2, Hironari Kato4,2, Kazuya Matsumoto5,2, Ichiro Moriyama6,2 1 Gastroenterology and Neurology, Kagawa University, Miki-cho Kitagun, Japan; 2Hakushusanbi Endoscopic Workshop Group, Okayama, Japan; 3General Medicine 2,, Kawasaki Medical School, Okayama, Japan; 4Dep. of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; 5Dept. of Gastroenterology, Tottori University, Tottori, Japan; 6Div. of Cancer Center, Shimane University, Izumo, Japan Introduction: Gastroduodenal outlet obstruction (GOO) is severe complication that often develops in patients with advanced cancer. GOO causes nausea, vomiting, intolerance to oral feeding, and diminishes the quality of life. Traditionally, the treatment for GOO has been surgical gastrojejunostomy. But the invasiveness of surgical therapy sometimes brings disadvantages for those patients because of their poor general condition. Recently, endoscopic placement of self-expanding metal stents (SEMS) is increasingly used as a less invasive treatment for the palliation of patients with GOO. However, there are few reports regarding long-
AB252 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
term outcomes of clinical course and adverse events as well as comparative results of various kinds of SEMS. Aims: The aim of this study is to evaluate the efficacy and safety of SEMS placement in a large number of patients with malignant GOO. Methods: This study was conducted at 5 institutions which belong to the Hakushusanbi Endoscopic Workshop Group, Japan from Apr. 2007 to May. 2014. We collected data of 125 patients, with a mean age of 70.2 years, treated with SEMS placement (Wallflex Enteral /Niti-S). The primary diseases were pancreatic cancer (NZ61), gastric cancer (NZ25), cholangiocarcinoma (NZ26), primary duodenal cancer (NZ1), other cancer (NZ12). The type of GOO was luminal obstruction in 24 patients and extraluminal invasion in 101 patients. Gastric outlet obstruction scoring system (GOOSS) was used to assess GOO; before stenting, 53 patients were in score 0, 36 in 1, 9 in 2, 27 in 3. Location of stenosis was antrum of stomach (NZ22), duodenal bulb (NZ29), duodenal descending part (NZ21), duodenal horizontal part (NZ4), multiple sites (NZ20). Wallflex were employed in 46 patients, and Niti-S in 79 patients. Technical and clinical success, procedure time, improvement of GOOSS, patency periods and adverse events were evaluated. Result: SEMS placement was technically successful in all patients. Clinical success was achieved in 90.4%. The mean procedure time was 22.7min. The mean GOOSS scores was improved from 1.091.16 to 2.730.06. The median SEMS patency periods was 137 days. The median survival period was 191 days. Among 12 cases whose GOOSS was less than 2, we analyzed clinical success rate according to primary diagnosis, type and location of stent, and origin of stenosis. Clinical success rate was 96.2% in Niti-S group and 84.8% in Wallflex group, significantly higher in Niti-S group (pZ0.010). Adverse events, such as tumor ingrowth, bleeding and stent occlusion occurred in 36patients (28.8%). One patient died of late onset massive bleeding. Conclusion: Endoscopic SEMS placement for malignant GOO is safe and effective. To achieve better clinical outcomes, we should be familiar with SEMS property, such as axial force and radial force to avoid serious complications including late onset massive bleeding.
Sa1534 Combination of Narrow Band Image, Chromoendoscopy and Endoscopic Ultrasonography to Predict Deep Submucosal Invasion in Scheduled ESD Patients Yu Sik Myung*, Bong Min Ko, Soo-Kyung Park, Hyeon Jeong Goong, Jae Pil Han, Seong Ran Jeon, Su Jin Hong, Moon Sung Lee Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea (the Republic of) Background and Objectives: Distinguishing deep submucosa (SM) invasion from superficial sm invasion in early colorectal cancer is important to determine the appropriate therapeutic strategies. Traditionally, magnification colonoscopy using chromoendoscopy and vascular pattern assessment using narrow band imaging (NBI) have been utilized. However, colonoscopic ultrasound using mini probe (EUM) is not used well because of the specialist equipment required and technical difficulty. The aim of this study was to evaluate the efficacy of combination of NBI, chromoendoscopy and EUM to predict deep sm invasion of early colorectal cancer. Methods: From March 2013 to June 2014, a total of 50 early colorectal cancer were analysis. All patients underwent magnifying chromoendoscopy (MCE) and NBI of the colorectal lesion during colonoscopic examination. If either MCE and NBI suggested deep sm invasion, we additionally performed EUM. If EUM suggested deep sm invasion, we finally decided deep sm cancer. Results: A total of 50 lesions in 48 patients were included in the final analysis. There were 27 intramucosal cancers, 23 submucosal cancer: 4 superficial (sm1) and 19 deep (sm 2-3) cancer. Diagnostic sensitivity, specificity positive predictive value (PPV), negative predictive value (NPV) and accuracy of MCE were 63.2, 96.7, 92.3, 81.0 and 8.0% for deep sm cancer. Diagnostic sensitivity, specificity, PPV, NPV and accuracy of NBI were 68.4, 83.8, 72.2, 81.3 and 78.0% for deep sm cancer. In combination with mini-probe EUS, the diagnostic sensitivity, specificity, PPV and NPV were 94.7, 87.1, 81.2, and 96.4% for deep SM cancer. The overall accuracy for assessing deep sm invasion was 90.0%. accuracy of mini-probe EUS is superior to MCE or NBI for prediction of deep sm invasion in protruding type (85.7, 76.1 and 76.1%). Accuracy rate of MCE and mini-probe EUS in Vi pit pattern were 64.7 and 82.4%. Conclusions: In patients with unclearly diagnosis by MCE and/or NBI, combination with mini-probe EUS may helpful for prediction of deep sm invasion in colorectal neoplasm.
Sa1535 ESD in Early Gastric Cancer-European Results for Guideline vs. Expanded Criteria Annette Schneider*, Andreas Probst, Hans Arnholdt, Matthias Anthuber, Helmut Messmann Klinikum Augsburg, Augsburg, Germany Background: Endoscopic submucosal dissection (ESD) allows curative resection of early gastric cancer (EGC). Suitable conditions for ESD of EGC along the “guideline criteria” (CG) are a lesions size !20 mm, the lack of ulceration or submucosal invasion and G1/G2 grading. Resections following the “expanded criteria” (EC) have shown promising results in Asian studies. However data from the western world are lacking so far. Aim: To compare en-bloc and R0 resection after ESD of EGC following guideline versus expanded criteria. Methods: Between
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ESD p-EMR (n[ 66) (n[ 39)
p
OR (CI 95%)
Time O 180 min % 180 min Size O 30 mm
25 (51) 24 (49) 41 (73.2) 15 (26.8)
0.02
2.62 (1.16 - 5.92)
18 (40.9) 26 (59.1)
!0.0001
% 30
48 (78.7) 13 (21.3)
5.33 (2.26 12.58)
Sa1532 Endoscopic Resection of Giant Colonic Polyps - Size Matters! Rupam Bhattacharyya*, Fergus Chedgy, Gaius R. Longcroft-Wheaton, Pradeep Bhandari Portsmouth Hospitals NHS Trust, Cosham, Portsmouth, United Kingdom Introduction: Colonic polyps sized 50mm and above are traditionally treated by surgical resection. Endoscopic resection has now become increasingly common as the expertise of western endoscopists improves. There is very little published literature on endoscopic resection of these giant polyps. Aims: To evaluate the feasibility, safety and efficacy of endoscopic resection of giant polyps R50mm in size. Methods: Prospective cohort study. All patients who underwent endoscopic resection of colonic polyps R50mm from 2007-2013 were prospectively entered into a database. We excluded all polyps with fibrosis related to previous intervention. All patients were tertiary referrals from experienced gastroenterologists. All procedures were performed by a single experienced endoscopist. Results: NZ124 polyps in 122 patients. Mean polyp sizeZ71mm. Range 50-170mm. 27(22%) in right colon and 97 (78%) in left colon. M:F ratio 1.1:1. All polyps were resected in a piecemeal fashion. The mean procedure time was 120 minutes (range 90 to 240).The complication rate was 11/124(8.9%). All these patients required inpatient stay. There were 9 bleeds (3 immediate and 6 delayed), 1 post polypectomy syndrome and 1 case of split muscle fibres (clipped endoscopically). 1 case of immediate bleeding required surgery to control the bleeding. All the others were managed conservatively. 4 of the 9 bleeds required blood transfusion. The complication rate was independent of polyp size, resection technique or site of the lesion. Follow up data was available for 90 polyps. The recurrence rate was 21/90(23.3%). Of the 21 recurrences, 16/21(76%) patients achieved complete clearance with a further 1 to 2 endoscopic procedures. The recurrence rate was significantly dependent on polyp size and was not dependent on the resection technique or the site of the lesion. Recurrence gradually increased with an increase in polyp size up to 70mm. Recurrence was seen in 3/34(8.8%) polyps %55mm, in 7/54(12.9%) polyps %60mm and in 9/63(14.2%) polyps % 70mm. However, in polyps O70mm, the recurrence rate greatly increased to 12/ 27(44%) (pZ0.002). Conclusion: It is safe and feasible to endoscopically resect polyps 50-170mm in size. Recurrence is significantly dependent on polyp size. Giant polyps resected endoscopically have a significant recurrence rate. The majority of these can be cleared by further endoscopic procedures. However, we believe that the recurrence rate in polyps above 70mm is very high and surgery should be considered in these cases. Complication rates are independent of size. Table 1. Effect of increasing polyp size on recurrence Size Recurrence 21/90 (23.3%)
%55mm 3/34 (8.8%)
%60mm 7/54 (12.9%)
%70mm O70mm 9/63 (14.2%) 12/27 (44.4%) pZ0.002
Sa1533 Current Issues and Future Perspective of Gastroduodenal Metal Stent Placement for Malignant GOO: Multicenter Experience Hideki Kamada*1,2, Hirofumi Kawamoto3,2, Hironari Kato4,2, Kazuya Matsumoto5,2, Ichiro Moriyama6,2 1 Gastroenterology and Neurology, Kagawa University, Miki-cho Kitagun, Japan; 2Hakushusanbi Endoscopic Workshop Group, Okayama, Japan; 3General Medicine 2,, Kawasaki Medical School, Okayama, Japan; 4Dep. of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan; 5Dept. of Gastroenterology, Tottori University, Tottori, Japan; 6Div. of Cancer Center, Shimane University, Izumo, Japan Introduction: Gastroduodenal outlet obstruction (GOO) is severe complication that often develops in patients with advanced cancer. GOO causes nausea, vomiting, intolerance to oral feeding, and diminishes the quality of life. Traditionally, the treatment for GOO has been surgical gastrojejunostomy. But the invasiveness of surgical therapy sometimes brings disadvantages for those patients because of their poor general condition. Recently, endoscopic placement of self-expanding metal stents (SEMS) is increasingly used as a less invasive treatment for the palliation of patients with GOO. However, there are few reports regarding long-
AB252 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
term outcomes of clinical course and adverse events as well as comparative results of various kinds of SEMS. Aims: The aim of this study is to evaluate the efficacy and safety of SEMS placement in a large number of patients with malignant GOO. Methods: This study was conducted at 5 institutions which belong to the Hakushusanbi Endoscopic Workshop Group, Japan from Apr. 2007 to May. 2014. We collected data of 125 patients, with a mean age of 70.2 years, treated with SEMS placement (Wallflex Enteral /Niti-S). The primary diseases were pancreatic cancer (NZ61), gastric cancer (NZ25), cholangiocarcinoma (NZ26), primary duodenal cancer (NZ1), other cancer (NZ12). The type of GOO was luminal obstruction in 24 patients and extraluminal invasion in 101 patients. Gastric outlet obstruction scoring system (GOOSS) was used to assess GOO; before stenting, 53 patients were in score 0, 36 in 1, 9 in 2, 27 in 3. Location of stenosis was antrum of stomach (NZ22), duodenal bulb (NZ29), duodenal descending part (NZ21), duodenal horizontal part (NZ4), multiple sites (NZ20). Wallflex were employed in 46 patients, and Niti-S in 79 patients. Technical and clinical success, procedure time, improvement of GOOSS, patency periods and adverse events were evaluated. Result: SEMS placement was technically successful in all patients. Clinical success was achieved in 90.4%. The mean procedure time was 22.7min. The mean GOOSS scores was improved from 1.091.16 to 2.730.06. The median SEMS patency periods was 137 days. The median survival period was 191 days. Among 12 cases whose GOOSS was less than 2, we analyzed clinical success rate according to primary diagnosis, type and location of stent, and origin of stenosis. Clinical success rate was 96.2% in Niti-S group and 84.8% in Wallflex group, significantly higher in Niti-S group (pZ0.010). Adverse events, such as tumor ingrowth, bleeding and stent occlusion occurred in 36patients (28.8%). One patient died of late onset massive bleeding. Conclusion: Endoscopic SEMS placement for malignant GOO is safe and effective. To achieve better clinical outcomes, we should be familiar with SEMS property, such as axial force and radial force to avoid serious complications including late onset massive bleeding.
Sa1534 Combination of Narrow Band Image, Chromoendoscopy and Endoscopic Ultrasonography to Predict Deep Submucosal Invasion in Scheduled ESD Patients Yu Sik Myung*, Bong Min Ko, Soo-Kyung Park, Hyeon Jeong Goong, Jae Pil Han, Seong Ran Jeon, Su Jin Hong, Moon Sung Lee Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea (the Republic of) Background and Objectives: Distinguishing deep submucosa (SM) invasion from superficial sm invasion in early colorectal cancer is important to determine the appropriate therapeutic strategies. Traditionally, magnification colonoscopy using chromoendoscopy and vascular pattern assessment using narrow band imaging (NBI) have been utilized. However, colonoscopic ultrasound using mini probe (EUM) is not used well because of the specialist equipment required and technical difficulty. The aim of this study was to evaluate the efficacy of combination of NBI, chromoendoscopy and EUM to predict deep sm invasion of early colorectal cancer. Methods: From March 2013 to June 2014, a total of 50 early colorectal cancer were analysis. All patients underwent magnifying chromoendoscopy (MCE) and NBI of the colorectal lesion during colonoscopic examination. If either MCE and NBI suggested deep sm invasion, we additionally performed EUM. If EUM suggested deep sm invasion, we finally decided deep sm cancer. Results: A total of 50 lesions in 48 patients were included in the final analysis. There were 27 intramucosal cancers, 23 submucosal cancer: 4 superficial (sm1) and 19 deep (sm 2-3) cancer. Diagnostic sensitivity, specificity positive predictive value (PPV), negative predictive value (NPV) and accuracy of MCE were 63.2, 96.7, 92.3, 81.0 and 8.0% for deep sm cancer. Diagnostic sensitivity, specificity, PPV, NPV and accuracy of NBI were 68.4, 83.8, 72.2, 81.3 and 78.0% for deep sm cancer. In combination with mini-probe EUS, the diagnostic sensitivity, specificity, PPV and NPV were 94.7, 87.1, 81.2, and 96.4% for deep SM cancer. The overall accuracy for assessing deep sm invasion was 90.0%. accuracy of mini-probe EUS is superior to MCE or NBI for prediction of deep sm invasion in protruding type (85.7, 76.1 and 76.1%). Accuracy rate of MCE and mini-probe EUS in Vi pit pattern were 64.7 and 82.4%. Conclusions: In patients with unclearly diagnosis by MCE and/or NBI, combination with mini-probe EUS may helpful for prediction of deep sm invasion in colorectal neoplasm.
Sa1535 ESD in Early Gastric Cancer-European Results for Guideline vs. Expanded Criteria Annette Schneider*, Andreas Probst, Hans Arnholdt, Matthias Anthuber, Helmut Messmann Klinikum Augsburg, Augsburg, Germany Background: Endoscopic submucosal dissection (ESD) allows curative resection of early gastric cancer (EGC). Suitable conditions for ESD of EGC along the “guideline criteria” (CG) are a lesions size !20 mm, the lack of ulceration or submucosal invasion and G1/G2 grading. Resections following the “expanded criteria” (EC) have shown promising results in Asian studies. However data from the western world are lacking so far. Aim: To compare en-bloc and R0 resection after ESD of EGC following guideline versus expanded criteria. Methods: Between
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