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Sa1634 Clinical Utility of the SMSA Polyp Grading Tool for the Management of Colonic Preneoplastic Lesions
Abstracts
Sa1632 Blue LASER Imaging-Bright Improves Visibility of Polyps: a Colonoscopy Video Evaluation Study Kiyoshi Ogiso*, Naohisa Yoshida, Kewin Tien Ho Siah, Ryohei Hirose, Osamu Dohi, Kazuhiro Katada, Kazuhiro Kamada, Kazuhiko Uchiyama, Osamu Handa, Tomohisa Takagi, Hideyuki Konishi, Yuji Naito, Yoshito Itoh Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan Background & Purpose: Previous studies with Narrow band imaging (NBI) failed to show improvement over high-definition white-light (HD-WL) in polyp detection. Polyp detection depends on visibility of polyps. Blue laser imaging is a novel Imageenhanced endoscopy. We previously reported the efficacy of BLI for acquiring clear surface blood vessel and surface structure and predicting tumor’s histopathological diagnosis (Yoshida et al. J Gastroenterol 2014). Blue laser imaging-bright (BLIbright) mode was recently shown to improve detection of tumors from a far field of view. The aim of this study was to investigate whether BLI-bright could improve the visibility of colorectal polyps compare to HD-WL. Material and method: We recorded movies of consecutive polyps found during colonoscopy (from April 2013 to November 2013) by an expert colonoscopist in Kyoto Prefectural University of Medicine. All polyps were positioned at the midpoint of the movie (5 cm proximal and 5 cm distal to a polyp). Two movies were captured for each polyp, one with BLIbright and one with HD-WL. Polyps location, size, morphology, and pathological diagnosis were recorded. All included movies were evaluated by a single expert endoscopist (O5000 colonoscopies performed). All polyps were graded according to their visibility; 4 for excellent, 3 for good, 2 for fair and 1 for poor visibility. Results: We studied 142 colorectal polyps in total (117 neoplastic lesions: 25 non-neoplastic lesions). There were 79 lesions in the right-sided colon, 42 in the left-sided colon, and 21 in the rectum. The mean tumor size was 9.1 mm (range: 2-20mm). 52 lesions were protruding and 90 lesions were flat polyp. The mean visibility score by BLI-bright were significantly higher than HD-WL (3.80.4 vs 3.10.1, P!0.05). 45.8% of polyps had a higher visibility score with BLI-bright. 52.8% of polyps shown no difference and 1.4% of polyps had better visibility score with HD-WL. When comparing morphology of polyps according to light superiority, there were more flat polyps in BLI-BrightOHD-WL group than BLI-bright%HD-WL group (72.3% vs 54.5% p!0.05). On the other hand, there were no significant differences about location (rate of right-sided colon), tumor size (rate of polyps less than 5mm), and pathological diagnosis (rate of neoplastic lesion) between BLI-brightOHD-WL group and BLI-bright%HD-WL group (Location: 52.3% vs 57.1%, N.S.) (Size: 27.6% vs 22.0%, N.S.) (Histology: 78.5% vs 85.7%, N.S.). Conclusion: Our study showed that polyps were more visible under BLI-bright compared to HD-WL. BLI-bright also makes flat polyp more visible. More studies should be done to determine whether BLI-bright can improve polyp detection rate.
Sa1633 Discrepancy Between Gastroenterologists’ and General Surgeons’ Perspectives on Repeat Endoscopy in Colorectal Cancer Arash Azin1, M. Carolina Jimenez1, Michelle C. Cleghorn1, Timothy Jackson1,2, Allan Okrainec1,2, Peter G. Rossos3,4, Fayez A. Quereshy*5,2 1 Division of General Surgery, University Health Network, Toronto, ON, Canada; 2Surgery, University of Toronto, Toronto, ON, Canada; 3 Division of Gastroenterology, University Health Network, Toronto, ON, Canada; 4Medicine, University of Toronto, Toronto, ON, Canada; 5 Surgical Oncology, University Health Network, Toronto, ON, Canada Background: Colonoscopy is the gold standard in the detection of colorectal cancer, but has a localization error rate as high as 21%. Therefore many surgeons consider repeat colonoscopy to be the standard of care. This study examines the localization practices of gastroenterologists and identifies and compares their perceptions toward preoperative repeat endoscopy to those of general surgeons. Methods: A questionnaire was developed based on a Medline literature review to ascertain the current localization practices and attitudes of gastroenterologists towards preoperative re-endoscopy for colorectal cancer. The preliminary survey was reviewed at a focus group consisting of two academic gastroenterologists, a community gastroenterologist, a gastroenterology resident, and a practicing general surgeon. The final questionnaire consisted of 16 questions that addressed demographic items, general localization practices, use of tattooing, and indications for and perspectives on reendoscopy. The survey was electronically distributed to practicing gastroenterologists through a provincial repository. Univariate analysis was performed using the Chi-squared test. Gastroenterologists’ attitudes and perceptions toward re-endoscopy in this setting were compared to the opinions of general surgeons, which were identified by a recent survey that was developed using similar methodology. Results: Gastroenterologists (NZ72) reported using anatomic landmarks (91.7%), tattooing (83.8%), and image capture (75.0%) for tumor localization. The majority said they would tattoo lesions that could not be removed by colonoscopy (93%), polyps with high-risk features (95.8%), and large lesions (84.7%). They were equally likely to tattoo lesions planned for laparoscopic (91.7%) or open (88.9%) resection. Rectal lesions were less likely to be tattooed (20.8%) than left-sided (90.3%) or right-sided (86.1%) lesions. Only 1.4% agreed that re-endoscopy is the
AB290 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
standard of care, compared to 38.9% (nZ68) of general surgeons; p!0.001. Gastroenterologists rated preoperative planning as the main indication for re-endoscopy (p!0.001), while general surgeons rated tattoo localization highest (pZ0.003) (Table 1). General surgeons were more likely to agree that an incomplete initial colonoscopy was an indication for re-endoscopy; pZ0.040. 56% of general surgeons indicated that the findings of re-endoscopy often lead to changes in the operative plan. Conclusions: This study demonstrates a discrepancy between the perspective of gastroenterologists and general surgeons towards preoperative repeat endoscopy for colorectal cancer and its indications. Further research is needed to formulate practice recommendations that guide the use of repeat endoscopy and tattoo localization, as well as standards for quality reporting between endoscopists. Table 1. Primary indication for repeat endoscopy prior to colorectal
cancer surgery identified by gastroenterologists and general surgeons Primary Indication Preoperative planning Tattoo localization by the operating surgeon Lack of information provided by initial colonoscopy report Incomplete initial colonoscopy Repeated therapeutic attempt
Gastroenterologists, N[72
General Surgeons, N[175
pvalue
48 (66.7) 10 (13.9)
49 (28.0) 50 (28.6)
0.000* 0.003*
8 (11.1)
24 (13.7)
0.350
5 (6.9) 1 (1.4)
26 (14.9) 3 (1.7)
0.040* 0.758
Values are presented as n (%). * p!0.05 was considered statistically significant.
Sa1634 Clinical Utility of the SMSA Polyp Grading Tool for the Management of Colonic Preneoplastic Lesions Stefano Sansone*1, Gianluca Rotondano1, Maria Antonia Bianco1, Sarmed S. Sami2, Sabina Beg2, Abhay Bagewadi2, Krish Ragunath2 1 Gastroenterology, Hospital Maresca, Torre del Greco, Italy; 2 Gastroenterology, Nottingham Digestive Diseases Center & NIHR Biomedical research Unit, Queens Medical Centre, Nottingham, United Kingdom Introduction: Whilst Polyp size has been traditionally used as a predictor of the complexity of endoscopic resection, the influence of other factors is increasingly recognised. The SMSA polyp grading system takes into account polyp Site, Morphology, Size and Access, with higher scores correlating with increased technical difficulty and a greater incidence of procedural complications. These findings are yet to be externally validated in a large cohort of patients. Aim: To evaluate whether the SMSA polyp grading tool correlates with endoscopic and clinical outcomes following endoscopic resection of colonic preneoplastic lesions. Methods: This retrospective study was conducted at two high volume tertiary referral centres in the United Kingdom and Italy, with colonoscopies performed by 7 experienced endoscopists. All polyps identified at colonoscopy were included in this study and were classified as per the SMSA polyp grading system. Data on the subsequent endoscopic resection, additional treatment, histology and major complications were collected. Results: A total of 1,668 lesions were resected in 1,016 patients. Using the SMSA grading tool, polyps were scored numerically before being classified as grade I, II, III or IV, with 372(22.3%), 625(37.5%), 502(30.1%) and 169(10.1%) in each group respectively. There was a positive correlation between increasing SMSA grade and the inability to resect lesions ‘en bloc’ (p!0.001). Histologically complete clearance achieved at the initial procedure was higher in the lower SMSA groups (p!0.001). Additional endoscopic therapies, such as APC or snare tip coagulation were more commonly required with the higher SMSA groups to achieve histological clearance (p!0.001). Moreover, advanced histology in resection specimens and procedural complications were significantly less common in SMSA grade I polyps compared to grade III or IV polyps (p!0.001). No patients with SMSA grade I polyps required referral for surgery, compared with 5.9% of those with grade IV polyps (p!0.001). Conclusions: This study demonstrates that the SMSA polyp grading tool is a useful predictor of outcomes following the resection of colonic preneoplastic lesions. Defining polyp complexity with the SMSA score may be useful in planning treatment strategies as well as the ability to individualise risk and provide prognostic information.
Sa1635 Technical Feasibility and Safety of Rectal Endoscopic Submucosal Dissection Over Three Fourth Circumference Seiichiro Abe*, Taku Sakamoto, Hiroyuki Takamaru, Masayoshi Yamada, Takeshi Nakajima, Takahisa Matsuda, Yutaka Saito Endoscopy division, National Cancer Center Hospital, Tokyo, Japan Background: Endoscopic submucosal dissection (ESD) has been applied for large rectal tumors and those located near the anal canal to achieve en bloc resection. It provides better quality of life by preserving rectal and anal function. In esophageal and gastric ESD, large mucosal defects over three fourth circumference is an independent risk factor of stenosis. There is limited data of feasibility and safety of rectal
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Sa1632 Blue LASER Imaging-Bright Improves Visibility of Polyps: a Colonoscopy Video Evaluation Study Kiyoshi Ogiso*, Naohisa Yoshida, Kewin Tien Ho Siah, Ryohei Hirose, Osamu Dohi, Kazuhiro Katada, Kazuhiro Kamada, Kazuhiko Uchiyama, Osamu Handa, Tomohisa Takagi, Hideyuki Konishi, Yuji Naito, Yoshito Itoh Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan Background & Purpose: Previous studies with Narrow band imaging (NBI) failed to show improvement over high-definition white-light (HD-WL) in polyp detection. Polyp detection depends on visibility of polyps. Blue laser imaging is a novel Imageenhanced endoscopy. We previously reported the efficacy of BLI for acquiring clear surface blood vessel and surface structure and predicting tumor’s histopathological diagnosis (Yoshida et al. J Gastroenterol 2014). Blue laser imaging-bright (BLIbright) mode was recently shown to improve detection of tumors from a far field of view. The aim of this study was to investigate whether BLI-bright could improve the visibility of colorectal polyps compare to HD-WL. Material and method: We recorded movies of consecutive polyps found during colonoscopy (from April 2013 to November 2013) by an expert colonoscopist in Kyoto Prefectural University of Medicine. All polyps were positioned at the midpoint of the movie (5 cm proximal and 5 cm distal to a polyp). Two movies were captured for each polyp, one with BLIbright and one with HD-WL. Polyps location, size, morphology, and pathological diagnosis were recorded. All included movies were evaluated by a single expert endoscopist (O5000 colonoscopies performed). All polyps were graded according to their visibility; 4 for excellent, 3 for good, 2 for fair and 1 for poor visibility. Results: We studied 142 colorectal polyps in total (117 neoplastic lesions: 25 non-neoplastic lesions). There were 79 lesions in the right-sided colon, 42 in the left-sided colon, and 21 in the rectum. The mean tumor size was 9.1 mm (range: 2-20mm). 52 lesions were protruding and 90 lesions were flat polyp. The mean visibility score by BLI-bright were significantly higher than HD-WL (3.80.4 vs 3.10.1, P!0.05). 45.8% of polyps had a higher visibility score with BLI-bright. 52.8% of polyps shown no difference and 1.4% of polyps had better visibility score with HD-WL. When comparing morphology of polyps according to light superiority, there were more flat polyps in BLI-BrightOHD-WL group than BLI-bright%HD-WL group (72.3% vs 54.5% p!0.05). On the other hand, there were no significant differences about location (rate of right-sided colon), tumor size (rate of polyps less than 5mm), and pathological diagnosis (rate of neoplastic lesion) between BLI-brightOHD-WL group and BLI-bright%HD-WL group (Location: 52.3% vs 57.1%, N.S.) (Size: 27.6% vs 22.0%, N.S.) (Histology: 78.5% vs 85.7%, N.S.). Conclusion: Our study showed that polyps were more visible under BLI-bright compared to HD-WL. BLI-bright also makes flat polyp more visible. More studies should be done to determine whether BLI-bright can improve polyp detection rate.
Sa1633 Discrepancy Between Gastroenterologists’ and General Surgeons’ Perspectives on Repeat Endoscopy in Colorectal Cancer Arash Azin1, M. Carolina Jimenez1, Michelle C. Cleghorn1, Timothy Jackson1,2, Allan Okrainec1,2, Peter G. Rossos3,4, Fayez A. Quereshy*5,2 1 Division of General Surgery, University Health Network, Toronto, ON, Canada; 2Surgery, University of Toronto, Toronto, ON, Canada; 3 Division of Gastroenterology, University Health Network, Toronto, ON, Canada; 4Medicine, University of Toronto, Toronto, ON, Canada; 5 Surgical Oncology, University Health Network, Toronto, ON, Canada Background: Colonoscopy is the gold standard in the detection of colorectal cancer, but has a localization error rate as high as 21%. Therefore many surgeons consider repeat colonoscopy to be the standard of care. This study examines the localization practices of gastroenterologists and identifies and compares their perceptions toward preoperative repeat endoscopy to those of general surgeons. Methods: A questionnaire was developed based on a Medline literature review to ascertain the current localization practices and attitudes of gastroenterologists towards preoperative re-endoscopy for colorectal cancer. The preliminary survey was reviewed at a focus group consisting of two academic gastroenterologists, a community gastroenterologist, a gastroenterology resident, and a practicing general surgeon. The final questionnaire consisted of 16 questions that addressed demographic items, general localization practices, use of tattooing, and indications for and perspectives on reendoscopy. The survey was electronically distributed to practicing gastroenterologists through a provincial repository. Univariate analysis was performed using the Chi-squared test. Gastroenterologists’ attitudes and perceptions toward re-endoscopy in this setting were compared to the opinions of general surgeons, which were identified by a recent survey that was developed using similar methodology. Results: Gastroenterologists (NZ72) reported using anatomic landmarks (91.7%), tattooing (83.8%), and image capture (75.0%) for tumor localization. The majority said they would tattoo lesions that could not be removed by colonoscopy (93%), polyps with high-risk features (95.8%), and large lesions (84.7%). They were equally likely to tattoo lesions planned for laparoscopic (91.7%) or open (88.9%) resection. Rectal lesions were less likely to be tattooed (20.8%) than left-sided (90.3%) or right-sided (86.1%) lesions. Only 1.4% agreed that re-endoscopy is the
AB290 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
standard of care, compared to 38.9% (nZ68) of general surgeons; p!0.001. Gastroenterologists rated preoperative planning as the main indication for re-endoscopy (p!0.001), while general surgeons rated tattoo localization highest (pZ0.003) (Table 1). General surgeons were more likely to agree that an incomplete initial colonoscopy was an indication for re-endoscopy; pZ0.040. 56% of general surgeons indicated that the findings of re-endoscopy often lead to changes in the operative plan. Conclusions: This study demonstrates a discrepancy between the perspective of gastroenterologists and general surgeons towards preoperative repeat endoscopy for colorectal cancer and its indications. Further research is needed to formulate practice recommendations that guide the use of repeat endoscopy and tattoo localization, as well as standards for quality reporting between endoscopists. Table 1. Primary indication for repeat endoscopy prior to colorectal
cancer surgery identified by gastroenterologists and general surgeons Primary Indication Preoperative planning Tattoo localization by the operating surgeon Lack of information provided by initial colonoscopy report Incomplete initial colonoscopy Repeated therapeutic attempt
Gastroenterologists, N[72
General Surgeons, N[175
pvalue
48 (66.7) 10 (13.9)
49 (28.0) 50 (28.6)
0.000* 0.003*
8 (11.1)
24 (13.7)
0.350
5 (6.9) 1 (1.4)
26 (14.9) 3 (1.7)
0.040* 0.758
Values are presented as n (%). * p!0.05 was considered statistically significant.
Sa1634 Clinical Utility of the SMSA Polyp Grading Tool for the Management of Colonic Preneoplastic Lesions Stefano Sansone*1, Gianluca Rotondano1, Maria Antonia Bianco1, Sarmed S. Sami2, Sabina Beg2, Abhay Bagewadi2, Krish Ragunath2 1 Gastroenterology, Hospital Maresca, Torre del Greco, Italy; 2 Gastroenterology, Nottingham Digestive Diseases Center & NIHR Biomedical research Unit, Queens Medical Centre, Nottingham, United Kingdom Introduction: Whilst Polyp size has been traditionally used as a predictor of the complexity of endoscopic resection, the influence of other factors is increasingly recognised. The SMSA polyp grading system takes into account polyp Site, Morphology, Size and Access, with higher scores correlating with increased technical difficulty and a greater incidence of procedural complications. These findings are yet to be externally validated in a large cohort of patients. Aim: To evaluate whether the SMSA polyp grading tool correlates with endoscopic and clinical outcomes following endoscopic resection of colonic preneoplastic lesions. Methods: This retrospective study was conducted at two high volume tertiary referral centres in the United Kingdom and Italy, with colonoscopies performed by 7 experienced endoscopists. All polyps identified at colonoscopy were included in this study and were classified as per the SMSA polyp grading system. Data on the subsequent endoscopic resection, additional treatment, histology and major complications were collected. Results: A total of 1,668 lesions were resected in 1,016 patients. Using the SMSA grading tool, polyps were scored numerically before being classified as grade I, II, III or IV, with 372(22.3%), 625(37.5%), 502(30.1%) and 169(10.1%) in each group respectively. There was a positive correlation between increasing SMSA grade and the inability to resect lesions ‘en bloc’ (p!0.001). Histologically complete clearance achieved at the initial procedure was higher in the lower SMSA groups (p!0.001). Additional endoscopic therapies, such as APC or snare tip coagulation were more commonly required with the higher SMSA groups to achieve histological clearance (p!0.001). Moreover, advanced histology in resection specimens and procedural complications were significantly less common in SMSA grade I polyps compared to grade III or IV polyps (p!0.001). No patients with SMSA grade I polyps required referral for surgery, compared with 5.9% of those with grade IV polyps (p!0.001). Conclusions: This study demonstrates that the SMSA polyp grading tool is a useful predictor of outcomes following the resection of colonic preneoplastic lesions. Defining polyp complexity with the SMSA score may be useful in planning treatment strategies as well as the ability to individualise risk and provide prognostic information.
Sa1635 Technical Feasibility and Safety of Rectal Endoscopic Submucosal Dissection Over Three Fourth Circumference Seiichiro Abe*, Taku Sakamoto, Hiroyuki Takamaru, Masayoshi Yamada, Takeshi Nakajima, Takahisa Matsuda, Yutaka Saito Endoscopy division, National Cancer Center Hospital, Tokyo, Japan Background: Endoscopic submucosal dissection (ESD) has been applied for large rectal tumors and those located near the anal canal to achieve en bloc resection. It provides better quality of life by preserving rectal and anal function. In esophageal and gastric ESD, large mucosal defects over three fourth circumference is an independent risk factor of stenosis. There is limited data of feasibility and safety of rectal
www.giejournal.org