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Safety and Usefulness of Endoscopic Submucosal Dissection (ESD) in Colorectal Neoplasms
Abstracts
T1477 Long-Term Follow-Up and Predictive Factors of Recurrence of Anemia in a Cohort of 102 Very Elderly Patients Explored for Iron Deficiency Anemia Ste´phane Nahon, Pierre Lahmek, Francine Barclay, Gilles Macaigne, Ce´cile Poupardin, Nicolas Delas, Bruno Lesgourgues
T1479 A Micro-Vascular Architecture with NBI Colonoscopy Is Useful to Predict Invasiveness and Allow Patients to Select for Endoscopic Resection Or Surgical Resection Takahiro Horimatsu, Hiroaki Ikematsu, Yasushi Sano, Atushi Katagiri, Kuang I. Fu, Atushi Ohtsu, Shigeaki Yoshida
Aim: To evaluate long-term follow-up and predictors of relapse of anemia in a cohort of 102 very elderly patients previously explored for iron-deficiency anemia (IDA). Methods: 102 patients [61 women, mean age 82 5.8 years, (75-98)] explored for IDA have been prospectively followed-up from inclusion (June 2003 to May 2005) until death or May 2006. Survival rate was estimated by the Kaplan-Meier method and compared by the log-rank test. Predictors of recurrence of anemia were identified by multivariate analysis in the four following subgroups: unexplained IDA (subgroup 1, n Z 27), benign lesion (subgroup 2, n Z 37), cancers treated curatively (subgroup 3, n Z 28), cancers treated palliatively (subgroup 4, n Z 10). Results: Median follow-up was 20 months. At baseline, main clinical and laboratory data were not significantly different in the four subgroups, especially severe comorbidities and ASA score. 33 patients died, 10 (30%) of them in the first month. Ten (100%) belonged to subgroup 4 vs respectively n Z 7 (26%), n Z 8 (22%) and n Z 8 (29%) of patients from subgroups 1, 2 and 3 (p ! 0.001). No death was directly related to recurrence of anemia. Survival rate at one year was 10% in subgroup 4 significantly lower than others 3 subgroups (subgroup 1 : 84%; subgroup 2 : 86%; subgroup 3 : 78% p ! 0.0001). Anemia recurred in 18 cases requiring red cell transfusion in 13 cases. Predictive factors of recurrence of anemia (OR [IC 95%], p) were: cancers treated palliatively (14.9 [3-72], p ! 0.01) and angiodysplasias [4.5 (1.1-18.2), 0.035]. Conclusion: In a cohort of very elderly patients explored for IDA, the mortality rate and the long-term survival were not different for patients with IDA related to a cancer treated curatively than those with unexplained IDA and those with IDA related to a benign lesion. Angiodysplasias and cancers treated palliatively were associated with recurrence of anemia. These results suggest interventionist strategies (including endoscopic investigation and appropriate surgery) for elderly patients with IDA.
Background: Colorectal submucosal invasive cancer (sm cancer) is a boundary lesion between endoscopic mucosal resection and conventional surgery with regional lymph-node resection. Because the frequency of LN metastasis is about 10% in the lesion, submucosal invasion was O1000 mm in non-pedunculated type, poorly adenocarcinoma, vascular invasion are given as condition to consider surgery resection in guideline of Japan. We reported that magnification using NBI colonoscopy for the observation of the presence of ‘‘meshed brown capillary (MC) vessels’’ extremely useful for distinguishing between non-neoplastic and neoplastic lesions without the application of any dye solution. Aim: To clarify the clinical usefulness of the observation of MC vessels to predict invasiveness and allow patients to be selected for endoscopic resection or surgical resection. Patients: From 2004 March to 2006 July, 27 colorectal lesions, which appeared capillary pattern type III (disorganized structure and increased density of micro-vessels) by NBI colonoscopy with magnification, participated in this study. Methods: The detected lesions were classified into the following two groups according to their density of micro vessel and lacking in uniformity of the diameter with micro vessels. We defined the lesion that the density of micro vessel is crowded and the diameter of micro vessels is lacking in uniformity is Type IIIA, and the density of micro vessels is loose and the diameter of micro vessels is thinner than those of CP type IIIA is Type IIIB. For histological examinations, the lesions finally were removed endoscopically or surgically. The accuracy rates of endoscopic diagnosis of the invading depth were evaluated by referring to the final pathological diagnosis. Results: 27 lesions were enrolled in this study. 27 colorectal lesions including 12 intramucosal and sm cancer !1000 mm (sm-shallow) and 15 sm cancer O1000 mm (sm-deep) were detected and evaluated on histology. The overall diagnostic accuracy, sensitivity, and specificity using the density of micro vessel and lacking in uniformity of the diameter with micro vessels for distinction between sm-shallow and sm-deep lesions was 82.4% (14/17), 93.3% (14/15) and 75.0% (9/12). Conclusion: The lesions with the density of micro vessels is loose and the diameter of micro vessels is thin (capillary pattern type IIIB) had a tendency to be pathologically diagnosed as submucosal massive cancer or more beyond. The observation of micro vascular architecture with NBI colonoscopy can be useful for assessment the depths of cancer invasion to submucosal layer of colorectal lesions.
T1478 Ulcerative Colitis in South India Jijo V. Cherian, Arun Kumar Muthusamy, Udhay Navaneetham, Jayanthi Venkatakrishnan, Malathi S. Malathi Aim: To study the natural history, demography, clinical profile and course of ulcerative colitis in SouthIndia. Methodology: Retrospective case records of all patients registered with UC in a tertiary care referral center in SouthIndia between Jan2001-Dec2005 were analyzed. Diagnosis of UC was based on clinical, endoscopic, histological and radiological features at presentation and on follow-up response to drug therapy and exclusion of infective cause. Demography and clinical presentation was obtained on a structured proforma and the profiles were also analyzed for riskfactors, complications and course of the disease. Results: A total of 70 patients were analysed. M:F ratio was 38:32 (1.19:1).The overall mean age of patients was 39.96 þ 17.9. There appears to be a bimodal distribution of cases, the first peak occurring between 21 & 40 yrs(44.3%) and the second peak between 51 & 70 yrs (34.3%). 8.6%patients in the study group were !15 yrs of age. Blood and mucus in stools was the commonest 81.4% patients. Only 5 (7.1%) patients reported to be smokers. 4 patients (5.7%) reported significant alcohol intake. Of the extraintestinal manifestations arthritis (21.4%) and sacroilitis (12.85%) were the commonest. Ocular manifestations, pyoderma gangrenosum and erythemanodosum occurred in 1 patient (1.4%) each. 5 patients (7.1%) reported precipitation of an acute attack of colitis with stressful life events.4 patients (5.7%) had history of IBD in the family out of which one had a family member suffering from crohns disease. 35 patients (51.4%) had pancolitis and 34 patients (48.6%) had leftsided colitis. Only one Patient (1.4%) with pancolitis had backwash leitis.Colonoscopically 9 (12.85%) patients had mild disease, 30 (42.85%) had moderate disease and 31(44.3%) had severe disease.Acute pancreatitis developed in 2 (2.86%) patients, stricture rectum in 1 (1.4%) patient and toxic megacolon in 2 (2.86%) patients. 1 (1.4%) developed a thrombotic complication while on follow up.4 patients (5.7%) underwent total colectomy with ileoanal anastomosis and 4 patients (5.7%) died on follow up.The remaining 62(88.6%) are in remission on medical therapy with occasional relapses that are responsive to steroids. Conclusions: Prevalence of ulcerative colitis is on the rise. A significant number of patients belonged to the paediatric age group. There appears to be a bimodal distribution in the age of presentation atleast among males. Blood and mucus diarrhea is the most common presentation and extraintestinal manifestations are distinctively rare. Smoking appears to be protective and most of the patients had colonoscopic evidence of moderate to severe colitis.Complications are not uncommon and the overall mortality is around 5.7%.
AB270 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
T1480 Safety and Usefulness of Endoscopic Submucosal Dissection (ESD) in Colorectal Neoplasms Bong-Min Ko, Moon Sung Lee, Kye Won Kwon, In Sup Jung, Su Jin Hong, Chang Beom Ryu, Young Seok Kim, Jong Ho Moon, Jin Oh Kim, Joo Young Cho, Joon Seong Lee, Chan Sup Shim, Boo Sung Kim Background: Recently, endoscopic submucosal dissection is becoming popular for large superficial colorectal neoplasm in Korea and Japan. However, it is considered difficult in the colon because the colonic wall is much thinner and location of lesion was difficult. ESD technique for large colorectal lesions is still controversial, except those in the rectum, because the rate of complications is still high even by the experts. Patients and Methods: During the period from May 2004 to Oct. 2006, thirty nine patients (24 men, 15 women; mean age 60.85 11.56 years) were enrolled in the study. The indications are tumor larger than 20 mm in diameter, IIc type tumor, absence of type Vn pit pattern or non -lifting sign. We used a hook knife, flex knife, IT knife. We divided to Rt. Colon and Lt. colon. We analyzed that safety and usefulness of ESD in right colon and left colon according to size, procedure time, remnant tumor, recurrent rate, complication rate. Results: In 39 patients, 17 of which were in the right colon (left colon, 22 patients). Mean size of colorectal tumor was 28.56 10.79 mm. Procedure mean time of ESD in colorectal neoplasms was 60.00 10.79 min. The relationship between tumor size and procedure time according to location (Rt. colon and Lt. colon) was not significant (p O 0.05). The relationship between remnant/recurrent tumor and location on the colon was not significant (p O 0.05). Perforation were 3 patients (3/39, 7.7%). Two patients recovered after conservative treatment. There was no recurrence during 345.19 243.55 days. Conclusions: ESD may be safety and usefulness for treating the precancerous lesions and superficial early colon cancer without metastasis. More outcomes research and technical advance will be needed. ESD will play an important role in the therapeutic strategy for colorectal tumors in the near future.
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T1477 Long-Term Follow-Up and Predictive Factors of Recurrence of Anemia in a Cohort of 102 Very Elderly Patients Explored for Iron Deficiency Anemia Ste´phane Nahon, Pierre Lahmek, Francine Barclay, Gilles Macaigne, Ce´cile Poupardin, Nicolas Delas, Bruno Lesgourgues
T1479 A Micro-Vascular Architecture with NBI Colonoscopy Is Useful to Predict Invasiveness and Allow Patients to Select for Endoscopic Resection Or Surgical Resection Takahiro Horimatsu, Hiroaki Ikematsu, Yasushi Sano, Atushi Katagiri, Kuang I. Fu, Atushi Ohtsu, Shigeaki Yoshida
Aim: To evaluate long-term follow-up and predictors of relapse of anemia in a cohort of 102 very elderly patients previously explored for iron-deficiency anemia (IDA). Methods: 102 patients [61 women, mean age 82 5.8 years, (75-98)] explored for IDA have been prospectively followed-up from inclusion (June 2003 to May 2005) until death or May 2006. Survival rate was estimated by the Kaplan-Meier method and compared by the log-rank test. Predictors of recurrence of anemia were identified by multivariate analysis in the four following subgroups: unexplained IDA (subgroup 1, n Z 27), benign lesion (subgroup 2, n Z 37), cancers treated curatively (subgroup 3, n Z 28), cancers treated palliatively (subgroup 4, n Z 10). Results: Median follow-up was 20 months. At baseline, main clinical and laboratory data were not significantly different in the four subgroups, especially severe comorbidities and ASA score. 33 patients died, 10 (30%) of them in the first month. Ten (100%) belonged to subgroup 4 vs respectively n Z 7 (26%), n Z 8 (22%) and n Z 8 (29%) of patients from subgroups 1, 2 and 3 (p ! 0.001). No death was directly related to recurrence of anemia. Survival rate at one year was 10% in subgroup 4 significantly lower than others 3 subgroups (subgroup 1 : 84%; subgroup 2 : 86%; subgroup 3 : 78% p ! 0.0001). Anemia recurred in 18 cases requiring red cell transfusion in 13 cases. Predictive factors of recurrence of anemia (OR [IC 95%], p) were: cancers treated palliatively (14.9 [3-72], p ! 0.01) and angiodysplasias [4.5 (1.1-18.2), 0.035]. Conclusion: In a cohort of very elderly patients explored for IDA, the mortality rate and the long-term survival were not different for patients with IDA related to a cancer treated curatively than those with unexplained IDA and those with IDA related to a benign lesion. Angiodysplasias and cancers treated palliatively were associated with recurrence of anemia. These results suggest interventionist strategies (including endoscopic investigation and appropriate surgery) for elderly patients with IDA.
Background: Colorectal submucosal invasive cancer (sm cancer) is a boundary lesion between endoscopic mucosal resection and conventional surgery with regional lymph-node resection. Because the frequency of LN metastasis is about 10% in the lesion, submucosal invasion was O1000 mm in non-pedunculated type, poorly adenocarcinoma, vascular invasion are given as condition to consider surgery resection in guideline of Japan. We reported that magnification using NBI colonoscopy for the observation of the presence of ‘‘meshed brown capillary (MC) vessels’’ extremely useful for distinguishing between non-neoplastic and neoplastic lesions without the application of any dye solution. Aim: To clarify the clinical usefulness of the observation of MC vessels to predict invasiveness and allow patients to be selected for endoscopic resection or surgical resection. Patients: From 2004 March to 2006 July, 27 colorectal lesions, which appeared capillary pattern type III (disorganized structure and increased density of micro-vessels) by NBI colonoscopy with magnification, participated in this study. Methods: The detected lesions were classified into the following two groups according to their density of micro vessel and lacking in uniformity of the diameter with micro vessels. We defined the lesion that the density of micro vessel is crowded and the diameter of micro vessels is lacking in uniformity is Type IIIA, and the density of micro vessels is loose and the diameter of micro vessels is thinner than those of CP type IIIA is Type IIIB. For histological examinations, the lesions finally were removed endoscopically or surgically. The accuracy rates of endoscopic diagnosis of the invading depth were evaluated by referring to the final pathological diagnosis. Results: 27 lesions were enrolled in this study. 27 colorectal lesions including 12 intramucosal and sm cancer !1000 mm (sm-shallow) and 15 sm cancer O1000 mm (sm-deep) were detected and evaluated on histology. The overall diagnostic accuracy, sensitivity, and specificity using the density of micro vessel and lacking in uniformity of the diameter with micro vessels for distinction between sm-shallow and sm-deep lesions was 82.4% (14/17), 93.3% (14/15) and 75.0% (9/12). Conclusion: The lesions with the density of micro vessels is loose and the diameter of micro vessels is thin (capillary pattern type IIIB) had a tendency to be pathologically diagnosed as submucosal massive cancer or more beyond. The observation of micro vascular architecture with NBI colonoscopy can be useful for assessment the depths of cancer invasion to submucosal layer of colorectal lesions.
T1478 Ulcerative Colitis in South India Jijo V. Cherian, Arun Kumar Muthusamy, Udhay Navaneetham, Jayanthi Venkatakrishnan, Malathi S. Malathi Aim: To study the natural history, demography, clinical profile and course of ulcerative colitis in SouthIndia. Methodology: Retrospective case records of all patients registered with UC in a tertiary care referral center in SouthIndia between Jan2001-Dec2005 were analyzed. Diagnosis of UC was based on clinical, endoscopic, histological and radiological features at presentation and on follow-up response to drug therapy and exclusion of infective cause. Demography and clinical presentation was obtained on a structured proforma and the profiles were also analyzed for riskfactors, complications and course of the disease. Results: A total of 70 patients were analysed. M:F ratio was 38:32 (1.19:1).The overall mean age of patients was 39.96 þ 17.9. There appears to be a bimodal distribution of cases, the first peak occurring between 21 & 40 yrs(44.3%) and the second peak between 51 & 70 yrs (34.3%). 8.6%patients in the study group were !15 yrs of age. Blood and mucus in stools was the commonest 81.4% patients. Only 5 (7.1%) patients reported to be smokers. 4 patients (5.7%) reported significant alcohol intake. Of the extraintestinal manifestations arthritis (21.4%) and sacroilitis (12.85%) were the commonest. Ocular manifestations, pyoderma gangrenosum and erythemanodosum occurred in 1 patient (1.4%) each. 5 patients (7.1%) reported precipitation of an acute attack of colitis with stressful life events.4 patients (5.7%) had history of IBD in the family out of which one had a family member suffering from crohns disease. 35 patients (51.4%) had pancolitis and 34 patients (48.6%) had leftsided colitis. Only one Patient (1.4%) with pancolitis had backwash leitis.Colonoscopically 9 (12.85%) patients had mild disease, 30 (42.85%) had moderate disease and 31(44.3%) had severe disease.Acute pancreatitis developed in 2 (2.86%) patients, stricture rectum in 1 (1.4%) patient and toxic megacolon in 2 (2.86%) patients. 1 (1.4%) developed a thrombotic complication while on follow up.4 patients (5.7%) underwent total colectomy with ileoanal anastomosis and 4 patients (5.7%) died on follow up.The remaining 62(88.6%) are in remission on medical therapy with occasional relapses that are responsive to steroids. Conclusions: Prevalence of ulcerative colitis is on the rise. A significant number of patients belonged to the paediatric age group. There appears to be a bimodal distribution in the age of presentation atleast among males. Blood and mucus diarrhea is the most common presentation and extraintestinal manifestations are distinctively rare. Smoking appears to be protective and most of the patients had colonoscopic evidence of moderate to severe colitis.Complications are not uncommon and the overall mortality is around 5.7%.
AB270 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
T1480 Safety and Usefulness of Endoscopic Submucosal Dissection (ESD) in Colorectal Neoplasms Bong-Min Ko, Moon Sung Lee, Kye Won Kwon, In Sup Jung, Su Jin Hong, Chang Beom Ryu, Young Seok Kim, Jong Ho Moon, Jin Oh Kim, Joo Young Cho, Joon Seong Lee, Chan Sup Shim, Boo Sung Kim Background: Recently, endoscopic submucosal dissection is becoming popular for large superficial colorectal neoplasm in Korea and Japan. However, it is considered difficult in the colon because the colonic wall is much thinner and location of lesion was difficult. ESD technique for large colorectal lesions is still controversial, except those in the rectum, because the rate of complications is still high even by the experts. Patients and Methods: During the period from May 2004 to Oct. 2006, thirty nine patients (24 men, 15 women; mean age 60.85 11.56 years) were enrolled in the study. The indications are tumor larger than 20 mm in diameter, IIc type tumor, absence of type Vn pit pattern or non -lifting sign. We used a hook knife, flex knife, IT knife. We divided to Rt. Colon and Lt. colon. We analyzed that safety and usefulness of ESD in right colon and left colon according to size, procedure time, remnant tumor, recurrent rate, complication rate. Results: In 39 patients, 17 of which were in the right colon (left colon, 22 patients). Mean size of colorectal tumor was 28.56 10.79 mm. Procedure mean time of ESD in colorectal neoplasms was 60.00 10.79 min. The relationship between tumor size and procedure time according to location (Rt. colon and Lt. colon) was not significant (p O 0.05). The relationship between remnant/recurrent tumor and location on the colon was not significant (p O 0.05). Perforation were 3 patients (3/39, 7.7%). Two patients recovered after conservative treatment. There was no recurrence during 345.19 243.55 days. Conclusions: ESD may be safety and usefulness for treating the precancerous lesions and superficial early colon cancer without metastasis. More outcomes research and technical advance will be needed. ESD will play an important role in the therapeutic strategy for colorectal tumors in the near future.
www.giejournal.org