- Email: [email protected]
Su1446 Endoscopic Submucosal Dissection (ESD) Versus Transanal Endoscopic Microsurgery (TEM) for the Treatment of Early Rectal Cancer
Abstracts
OR⫽1.05; 95% CI: 0.46-2.41, and for proximal SSPs, OR⫽0.91; 95% CI: 0.60-1.40). Type of endoscopy procedure also did not affect the association between prior endoscopy and SSPs (for participants with only sigmoidoscopy, OR⫽0.96; 95% CI: 0.61-1.51, for those with only colonoscopy, OR⫽1.00; 95% CI: 0.58-1.73, and for participants with a history of both procedures, OR⫽0.82; 95% CI: 0.47-1.44). Conclusions: Our results suggest that unlike advanced adenomas and CRC, prior endoscopy is not associated with a reduced risk of SSPs. Because SSPs are found most often in the proximal colon, our findings may have important implications for proximal colon cancer prevention.
Su1444 High Adenoma Detection Rate and Adherence to Guidelines in Clinical Colonoscopy Practice Michael J. Bartel*1, Douglas Robertson2, Joseph C. Anderson2, Heiko Pohl2 1 Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH; 2 Gastroenterology, VA Medical Center, White River Junction, VT Backround & Aim: To minimize waits and delays for colonoscopy within Veterans Affair Medical Centers (VA), many VA centers utilize ‘fee-basis’ contract work to local non-VA facilities. These fee-basis colonoscopies are performed at regional facilities with varying practice patterns and should therefore represent common clinical colonoscopy practice. Prior work suggests that endoscopists often recommend shorter follow up than endorsed by guidelines. Our aim was to compare the quality of referred fee-basis colonoscopies to colonoscopies performed at the VA medical center by examining adherence to surveillance guidelines and adenoma detection rate. Methods: We included patients over the age of 50 years who were referred for a surveillance and screening fee-basis colonoscopy from the VA White River Junction, VT, to non-VA facilities between 2007-2010 (n⫽356, mean age 63.6, SD ⫾8.1; 94% male). These patients were matched to patients who underwent a routine screening or surveillance colonoscopy at the VA Medical Center by gender, age and year of procedure (n⫽356, mean age 63.3, SD ⫾7.8; 94% male). We used a standardized data abstraction form to the colonoscopy and pathology reports to obtain endoscopic findings and the recommended surveillance interval. The main outcome of interest was the adenoma detection rate and the proportion of colonoscopies with a recommended surveillance interval adherent to current guidelines (2008 Multisociety Guidelines). Results: Fee-basis colonoscopies were performed in 28 nonacademic (54%) and two academic facilities (46%). Gastroenterologists performed the majority of fee-basis colonoscopies (69%) with the remaining being performed by surgeons. All VA colonoscopies were performed by staff gastroenterologists from the VA and the affiliated academic medical center. The adenoma detection rate was 38.8% for fee-basis colonoscopies and 53.4% for VA performed colonoscopies (p⬍0.001) with a mean of 0.73 adenomas and 1.5 adenomas per patients in either group (p⬍0.001). Similarly, advanced adenomas were more frequently found during VA performed colonoscopies (23.6%) compared to fee-basis colonoscopies (13.2%, p⬍0.001). Recommendations for surveillance examination were available for 75.0% of fee-basis colonoscopies and 93.5% for VA colonoscopies (p⬍0.001). Fee-basis colonoscopy and VA performed colonoscopy recommendations were similarly adherent to current guidelines (83.2% vs. 87.7%). Conclusion: Adherence to current colonoscopy surveillance guidelines is high, both at a VA Medical Center and in the community practice surrounding the VA. Adenoma detection rate in this predominantly male veteran population is far above the quality benchmark of 25% in both groups, however, significantly higher when performed at the VA Medical Center. These findings suggest a need for a revaluation of benchmarks in male patients. Factor
VA (nⴝ356)
Fee-basis (nⴝ356)
p-value
Age Gender (% Male) Adenoma Detection Rate Advanced Adenomas Adherence to Guidelines Shorter Surveillance Interval than recommended in Guidelines Longer Surveillance Interval than recommended in Guidelines
63.3, SD ⫾7.8 94% 53.4% 23.6% 87.7% 6.3%
63.6, SD ⫾8.1 94% 38.8% 13.2% 83.2% 12.7%
NS NS ⬍0.001 ⬍0.001 NS NS
6.0%
4.1%
NS
Su1445 Adenoma Detection on Repeat Colonoscopy After Previous Inadequate Preparation Abhik Roy1, Colin L. Smith*1, Anjeli Prabhu1, Constantine Daskalakis2, David M. Kastenberg3 1 Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, PA; 2Biostatistics, Thomas Jefferson University Hospital, Philadelphia, PA; 3Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA Background: Endoscopists often perform an early repeat colonoscopy (“Repeat”)
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after an inadequately prepped colonoscopy (“Index”). Whether Repeat colonoscopy for inadequate cleansing has a significantly higher adenoma detection rate over that reported during tandem colonoscopy is not well established. Purpose: To investigate if the adenoma detection rate on Repeat colonoscopy following Index colonoscopy with inadequate preparation is significantly greater than the established miss rate. Methods: Our endoscopy database was queried between 2/09-2/10 for patients who had a colonoscopy with inadequate preparation and a Repeat study within 18 months. Colonoscopy, pathology, and patient data were abstracted from the colonoscopy report and electronic medical record. Polyps had to have unambiguous histologic results. Multiple polyps in a single pathology container with mixed histology counted as 1 adenoma. Surveillance interval calculations relied on consensus guidelines. Miss rates were calculated as # of new adenomas/total # of adenomas. The assumed miss rate for adenomas was 22% based on a published tandem colonoscopy meta-analysis. Per-patient miss rate was defined as the fraction of patients found to have a new adenoma on Repeat, and this was assumed to be 30% for adenomas based on a tandem colonoscopy study. Analyses of miss rates, overall and per-patient, were based on logistic regression. Using a 2-sided test with ␣⫽0.05, this study had 80% power to distinguish an adenoma miss rate of about 33% from 22%. Results: Of 538 patients with inadequate preparation on Index colonoscopy, 127 underwent a Repeat study within 18 months and were eligible. Table 1 describes patient characteristics. Index colonoscopy was performed for screening in 34% and surveillance/symptoms in 66%, and cecal intubation was achieved in 67%. On Repeat, 40% had inadequate cleansing and the cecum was intubated in 92%. The estimated miss rate was 52% for polyps (167/324) and 52% for adenomas (79/152). The adenoma miss rate was significantly higher than expected (95% CI: 43%, 61%; p⫽0.001). The adenoma per-patient miss rate was also significantly greater than reported with tandem colonoscopy (39% vs. 30%; 95% CI: 31%, 47%; p⫽0.036) Adenoma miss rates did not vary by location (53% right vs. 52% left colon) or size (p⫽0.174), but were significantly higher for each size category as compared to tandem colonoscopies (57% vs. 26% for ⬍5mm, p⫽0.001; 37 vs. 13% for 5-9mm, p⫽0.002; 47% vs. 2% for ⬎10mm, p⫽0.001). For 27% of patients, discovery of additional adenomas on Repeat shortened the interval for surveillance as per guidelines. Conclusions: The adenoma miss rate after colonoscopy with inadequate preparation is significantly higher than expected. This significant increase in missed lesions occurred in both the right and left colon and across all size categories analyzed. Table 1. Summary of subject characteristics (N ⴝ 127). Age (years), mean ⴞ sd Age (years), n (%) 50-59 60-69 70⫹ Sex, n (%) Male Female Time between initial and repeat colonoscopy (months), mean ⫾ std Time between initial and repeat colonoscopy (months), n (%) 0-3 4-6 7-12 ⬎12
61
ⴞ9
65 37 25
(51) (29) (20)
63 64 6
(50) (50) ⫾5
40 36 26 25
(32) (28) (20) (20)
Su1446 Endoscopic Submucosal Dissection (ESD) Versus Transanal Endoscopic Microsurgery (TEM) for the Treatment of Early Rectal Cancer Fabio S. Kawaguti*1, Caio Sergio R. Nahas2, Carlos Frederico S. Marques2, Bruno C. Martins1, Felipe A. Retes1, Marcelo S. Lima1, Cezar F. Sato1, Raphael S. De Medeiros3, Sergio C. Nahas2, Paulo Sakai4, Fauze Maluf-Filho1 1 Endoscopy Division, Cancer Institute of São Paulo University Medical School, São Paulo, Brazil; 2Oncologic Gastrointestinal Surgery Division, Cancer Institute of São Paulo University Medical School, São Paulo, Brazil; 3Pathology Division, Cancer Institute of São Paulo University Medical School, São Paulo, Brazil; 4Unit of Endoscopy, Clinics Hospital of São Paulo University Medical School, São Paulo, Brazil Introduction: Endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) are minimally invasive procedures that can be used to treat early rectal cancer (large rectal adenomas, intramucosal cancers and superficial submucosal cancers). The purpose of this study was to compare clinical efficacy between ESD and TEM for the treatment of early rectal cancer. Methods: Between July 2008 and August 2011, 22 patients with early rectal cancers were treated by ESD (10) or TEM (12) at Cancer Institute of São Paulo University Medical School (São Paulo, Brazil). Data was analyzed retrospectively according to database and pathological reports, with respect to en-bloc resection rate, resection margins, local recurrence, early complications (30 days), histological
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Abstracts
diagnosis, procedure time and length of hospital stay in both groups. Results: Mean tumor size was 64mm in ESD group and 45mm in TEM group (p⫽0,36). En-bloc resection rates with free margins were achieved in 80% (8/10) in ESD group and 83% (10/12) in TEM group (p⫽0,53). There was only one case of local recurrence in this study, observed in TEM group, 15 months after the index procedure. Postoperative complications in ESD group were two rectal perforations with pneumothorax and subcutaneous emphysema both managed conservatively, and one case of post-polypectomy syndrome. In the TEM group one patient presented temporary fecal incontinence and difficult defecation (130 mm size adenoma). Histological diagnosis showed 1 adenoma, 8 intramucosal cancer and 1 carcinoid tumor invading superficially the submucosa in ESD group. The TEM group showed 4 adenomas, 7 intramucosal cancers and 1 superficial submucosal cancer. In ESD group the mean procedure time was 133 min and in TEM group, 150 min (p⫽0,69). Mean hospital stay was 3,8 days in ESD group and 4,1 days in TEM group (p⫽0,81). Conclusion: Both techniques present good efficacy for the treatment of early rectal cancer, with similar enbloc complete resection rates. In ESD group, there was a higher rate of complications, probably related to the long learning curve of this particular endoscopic procedure.
Su1447 Colorectal Surveillance Interval Assignment Based on In-Vivo Prediction of Polyp Histology: Impact of Endoscopic Quality Improvement Program Susan G. Coe*1, Colleen S. Thomas2, Julia Crook2, Nancy Diehl2, Michael B. Wallace1 1 Gastroenterology, Mayo Clinic, Jacksonville, FL; 2Biostatistics, Mayo Clinic, Jacksonville, FL Introduction: In-vivo predictions of polyp histology, without pathological confirmation, (“resect and discard” or “diagnose and leave behind” strategies) has been proposed as a strategy to reduce health care costs associated with CRC prevention. Recent ASGE guidelines mandate a high level of accuracy for in vivo triage compared to standard pathologic prediction of post-polypectomy surveillance intervals. We hypothesized that an endoscopist training intervention would result in improvement in post-polypectomy surveillance prediction. Methods: As part of a larger prospective randomized study on endoscopist training in colonoscopy, endoscopists were asked to predict the histopathology of all resected polyps during routine colonoscopy and to assign colon cancer surveillance intervals using consensus guidelines. Data were prospectively collected for consecutive outpatient colonoscopies between 8/2 and 04/11/2011, including procedure indication, demographics and risk factors, polyp description, endoscopist prediction of histopathology and actual histopathology. Procedures were excluded if incomplete, had poor bowel prep (BBPS ⬍5), or had an indication of post-cancer surveillance, inflammatory bowel disease, hereditary syndrome surveillance, newly found cancer or active gastrointestinal hemorrhage. Polyps ⱖ10mm were considered “neoplastic” for the purposes of surveillance interval assignment. Comparisons of surveillance interval prediction accuracies were made for each group of study endoscopists (trained and not trained) before (Phase I) and after (Phase II) the training intervention period. Results: Of the 2400 colonoscopies, 1231 patients were found to have polyps. In the group of endoscopists who did not receive training, “optically predicted” surveillance intervals based solely on number of predicted adenomas and size of the largest polyp (independent of risk factors) had an overall accuracy of 81% (236/290) in Phase I and 79% in Phase II (265/337). The group that received training had an overall accuracy of 84% (242/287) in Phase I (prior to training) and 82% (261/317) in Phase II (after training). There was little evidence to suggest that training had a direct, detectable impact on the accuracy of optically predicted surveillance intervals (OR: 1.20, 95% CI: 0.76-1.89, P⫽0.44). When individual patient risk factors were considered the results were similar. Conclusion: Baseline accuracy for optical predication of surveillance intervals is modest. Endoscopist training did not result in improvement of “opticallypredicted” surveillance interval accuracy. These findings highlight the likely need for further studies on methods to train endoscopists to accurately predict polyp histology. Accuracy of optically predicted vs. pathology determined surveillance intervals (no training group) based on # of adenomas and size of largest polyp Phase I
No Training
Accuracy of optically predicted vs. pathology determined surveillance intervals (training group) based on # of adenomas and size of largest polyp Phase I
Training
Pathology determined interval 10 yrs
5 yrs
10yrs 5yrs 3yrs 3mth–1yr
43 44 1 0
26 103 8 2
3 3mthyrs 1yr
10 yrs
5 yrs
3 yrs
3mth1yr
1 3 42 2
10 yrs 5 yrs 3 yrs 3mth – 1yr
39 60 4 1
14 120 13 1
0 0 59 8
0 0 1 17
0 0 0 15
Phase I Accuracy: 70.0% (203/290) Phase II Accuracy: 69.7% (235/337) Bold indicates agreement.
Pathology determined interval
10 yrs
5 yrs
3 3mnthyrs 1yr
Optically predicted interval
10 yrs
5 yrs
3 yrs
3mnth1yr
48 30 3 0
21 107 4 4
0 4 44 4
10 yrs 5 yrs 3 yrs 3mnth-1yr
41 47 3 0
17 130 14 1
0 2 45 6
0 0 0 11
0 1 1 16
Phase I accuracy: 74.9% (215/287) Phase II accuracy: 71.6% (227/317) Bold indicates agreement.
Su1448 Relationship of Non-Alcoholic Fatty Liver Disease to Colorectal Neoplasia Jue Yong Lee*, Ja Won Kim, Sun Pil Choi, Jong Ho Park, Yeon Ho Joo Division of Gastroenterology, Changwon Fatima Hosp, Changwon, Republic of Korea Background and Aims: Metabolic syndrome is associated with an increased risk for colorectal cancer. Non-alcoholic fatty liver disease (NAFLD) is regarded as a hepatic manifestation of metabolic syndrome. Increased echogenicity suggesting NAFLD is a frequent incidental finding on ultrasound examination. In this study, we aimed to determine whether NAFLD has a relationship to colorectal neoplasia. Methods: A consecutive series of 1938 individuals who underwent screening colonoscopy at Changwon Fatima Hospital as part of their employer provided wellness program between Jan. 2009 and Sept. 2011 were reviewed. We divided the 1938 individuals into the adenoma group (n ⫽ 494) and the control group (n ⫽ 1444). Advanced neoplasia was defined as tubular adenoma measuring 1cm or larger, any villous histology, high grade dysplasia, or cancer. Excluded were those individuals with previous history of any malignancy or colorectal adenoma, family history of colorectal neoplasia (including adenomatous polyp), viral hepatitis, and those who drink moderately (alcohol consumption ⬎ 20 g/day). NAFLD was diagnosed by increased echogenicity on abdominal ultrasound. Results: The prevalence of NAFLD was 171 (34.6%) in the adenoma group and 336 (23.3%) in the control group. Compared with normal subjects, the adenoma group subjects were more likely to be men, had an older age, higher BMI, blood pressure, waist circumference, fasting glucose, uric acid, total cholesterol, triglyceride, HbA1c, Hb and ␥GT levels, and a higher prevalence of NAFLD, metabolic syndrome, diabetes mellitus, and hypertension (Table 1). From the multiple logistic regression analysis, older age (ⱖ 50 years), male sex, and prevalence of NAFLD were associated with an increased risk (OR, 2.046; 95% CI, 1.644-2.548; p ⬍ 0.001, OR, 2.395; 95% CI, 1.835-3.125; p ⬍ 0.001, and OR, 1.302; 95% CI, 1.022-1.659; p ⫽ 0.033, respectively) (Table 2). Conclusion: NAFLD is associated with a high prevalence of colorectal neoplasia. Colorectal cancer screening is strongly suggested in those individuals who detected fatty liver on abdominal ultrasound. Table 2. Univariate and multivariate analysis of the risk for colorectal neoplasia by age, gender, NAFLD, metabolic syndrome, hypertension, and diabetes mellitus Control group Adenoma group n ⴝ 1444 (74.5%) n ⴝ 494 (25.5%) ⬍50 ⭌50
1019 (71%) 425 (29%)
Female Male
510 (35%) 934 (65%)
No Yes
1108 (77%) 336 (23%)
No Yes
1218 (91%) 121 (9%)
No Yes
1182 (82%) 262 (18%)
No Yes
1386 (96%) 57 (4%)
Pathology determined interval
Optically predicted interval
Optically predicted interval 10 yrs 5 yrs 3 yrs 3mnth1yr
Phase II
Optically predicted interval
Phase II Pathology determined interval
Univariate analysis OR (95% CI)
Multivariate analysis
p
OR (95% CI)
p
Age (years) 262 (53%) 1 1 232 (47%) 2.123 (1.721–2.619) ⬍0.001 2.046 (1.644–2.548) ⬍0.001 Gender 87 (18%) 1 1 407 (82%) 2.558 (1.980–3.300) ⬍0.001 2.395 (1.835–3.125) ⬍0.001 NAFLD 323 (65%) 1 1 171 (35%) 1.746 (1.398–2.180) ⬍0.001 1.302 (1.022–1.659) 0.033 Metabolic syndrome 377 (77%) 1 1 114 (23%) 1.667 (1.293–2.148) ⬍0.001 1.246 (0.937–1.659) 0.131 Hypertension 369 (75%) 1 1 125 (25%) 1.528 (1.199–1.949) 0.002 1.130 (0.868–1.471) 0.365 Diabetes mellitus 458 (93%) 1 1 36 (7%) 1.911 (1.243–2.939) 0.005 1.249 (0.790–1.977) 0.341
CI, confidence interval; NAFLD, non-alcoholic fatty liver disease; OR, odds ratio.
AB335 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
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OR⫽1.05; 95% CI: 0.46-2.41, and for proximal SSPs, OR⫽0.91; 95% CI: 0.60-1.40). Type of endoscopy procedure also did not affect the association between prior endoscopy and SSPs (for participants with only sigmoidoscopy, OR⫽0.96; 95% CI: 0.61-1.51, for those with only colonoscopy, OR⫽1.00; 95% CI: 0.58-1.73, and for participants with a history of both procedures, OR⫽0.82; 95% CI: 0.47-1.44). Conclusions: Our results suggest that unlike advanced adenomas and CRC, prior endoscopy is not associated with a reduced risk of SSPs. Because SSPs are found most often in the proximal colon, our findings may have important implications for proximal colon cancer prevention.
Su1444 High Adenoma Detection Rate and Adherence to Guidelines in Clinical Colonoscopy Practice Michael J. Bartel*1, Douglas Robertson2, Joseph C. Anderson2, Heiko Pohl2 1 Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH; 2 Gastroenterology, VA Medical Center, White River Junction, VT Backround & Aim: To minimize waits and delays for colonoscopy within Veterans Affair Medical Centers (VA), many VA centers utilize ‘fee-basis’ contract work to local non-VA facilities. These fee-basis colonoscopies are performed at regional facilities with varying practice patterns and should therefore represent common clinical colonoscopy practice. Prior work suggests that endoscopists often recommend shorter follow up than endorsed by guidelines. Our aim was to compare the quality of referred fee-basis colonoscopies to colonoscopies performed at the VA medical center by examining adherence to surveillance guidelines and adenoma detection rate. Methods: We included patients over the age of 50 years who were referred for a surveillance and screening fee-basis colonoscopy from the VA White River Junction, VT, to non-VA facilities between 2007-2010 (n⫽356, mean age 63.6, SD ⫾8.1; 94% male). These patients were matched to patients who underwent a routine screening or surveillance colonoscopy at the VA Medical Center by gender, age and year of procedure (n⫽356, mean age 63.3, SD ⫾7.8; 94% male). We used a standardized data abstraction form to the colonoscopy and pathology reports to obtain endoscopic findings and the recommended surveillance interval. The main outcome of interest was the adenoma detection rate and the proportion of colonoscopies with a recommended surveillance interval adherent to current guidelines (2008 Multisociety Guidelines). Results: Fee-basis colonoscopies were performed in 28 nonacademic (54%) and two academic facilities (46%). Gastroenterologists performed the majority of fee-basis colonoscopies (69%) with the remaining being performed by surgeons. All VA colonoscopies were performed by staff gastroenterologists from the VA and the affiliated academic medical center. The adenoma detection rate was 38.8% for fee-basis colonoscopies and 53.4% for VA performed colonoscopies (p⬍0.001) with a mean of 0.73 adenomas and 1.5 adenomas per patients in either group (p⬍0.001). Similarly, advanced adenomas were more frequently found during VA performed colonoscopies (23.6%) compared to fee-basis colonoscopies (13.2%, p⬍0.001). Recommendations for surveillance examination were available for 75.0% of fee-basis colonoscopies and 93.5% for VA colonoscopies (p⬍0.001). Fee-basis colonoscopy and VA performed colonoscopy recommendations were similarly adherent to current guidelines (83.2% vs. 87.7%). Conclusion: Adherence to current colonoscopy surveillance guidelines is high, both at a VA Medical Center and in the community practice surrounding the VA. Adenoma detection rate in this predominantly male veteran population is far above the quality benchmark of 25% in both groups, however, significantly higher when performed at the VA Medical Center. These findings suggest a need for a revaluation of benchmarks in male patients. Factor
VA (nⴝ356)
Fee-basis (nⴝ356)
p-value
Age Gender (% Male) Adenoma Detection Rate Advanced Adenomas Adherence to Guidelines Shorter Surveillance Interval than recommended in Guidelines Longer Surveillance Interval than recommended in Guidelines
63.3, SD ⫾7.8 94% 53.4% 23.6% 87.7% 6.3%
63.6, SD ⫾8.1 94% 38.8% 13.2% 83.2% 12.7%
NS NS ⬍0.001 ⬍0.001 NS NS
6.0%
4.1%
NS
Su1445 Adenoma Detection on Repeat Colonoscopy After Previous Inadequate Preparation Abhik Roy1, Colin L. Smith*1, Anjeli Prabhu1, Constantine Daskalakis2, David M. Kastenberg3 1 Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, PA; 2Biostatistics, Thomas Jefferson University Hospital, Philadelphia, PA; 3Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA Background: Endoscopists often perform an early repeat colonoscopy (“Repeat”)
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after an inadequately prepped colonoscopy (“Index”). Whether Repeat colonoscopy for inadequate cleansing has a significantly higher adenoma detection rate over that reported during tandem colonoscopy is not well established. Purpose: To investigate if the adenoma detection rate on Repeat colonoscopy following Index colonoscopy with inadequate preparation is significantly greater than the established miss rate. Methods: Our endoscopy database was queried between 2/09-2/10 for patients who had a colonoscopy with inadequate preparation and a Repeat study within 18 months. Colonoscopy, pathology, and patient data were abstracted from the colonoscopy report and electronic medical record. Polyps had to have unambiguous histologic results. Multiple polyps in a single pathology container with mixed histology counted as 1 adenoma. Surveillance interval calculations relied on consensus guidelines. Miss rates were calculated as # of new adenomas/total # of adenomas. The assumed miss rate for adenomas was 22% based on a published tandem colonoscopy meta-analysis. Per-patient miss rate was defined as the fraction of patients found to have a new adenoma on Repeat, and this was assumed to be 30% for adenomas based on a tandem colonoscopy study. Analyses of miss rates, overall and per-patient, were based on logistic regression. Using a 2-sided test with ␣⫽0.05, this study had 80% power to distinguish an adenoma miss rate of about 33% from 22%. Results: Of 538 patients with inadequate preparation on Index colonoscopy, 127 underwent a Repeat study within 18 months and were eligible. Table 1 describes patient characteristics. Index colonoscopy was performed for screening in 34% and surveillance/symptoms in 66%, and cecal intubation was achieved in 67%. On Repeat, 40% had inadequate cleansing and the cecum was intubated in 92%. The estimated miss rate was 52% for polyps (167/324) and 52% for adenomas (79/152). The adenoma miss rate was significantly higher than expected (95% CI: 43%, 61%; p⫽0.001). The adenoma per-patient miss rate was also significantly greater than reported with tandem colonoscopy (39% vs. 30%; 95% CI: 31%, 47%; p⫽0.036) Adenoma miss rates did not vary by location (53% right vs. 52% left colon) or size (p⫽0.174), but were significantly higher for each size category as compared to tandem colonoscopies (57% vs. 26% for ⬍5mm, p⫽0.001; 37 vs. 13% for 5-9mm, p⫽0.002; 47% vs. 2% for ⬎10mm, p⫽0.001). For 27% of patients, discovery of additional adenomas on Repeat shortened the interval for surveillance as per guidelines. Conclusions: The adenoma miss rate after colonoscopy with inadequate preparation is significantly higher than expected. This significant increase in missed lesions occurred in both the right and left colon and across all size categories analyzed. Table 1. Summary of subject characteristics (N ⴝ 127). Age (years), mean ⴞ sd Age (years), n (%) 50-59 60-69 70⫹ Sex, n (%) Male Female Time between initial and repeat colonoscopy (months), mean ⫾ std Time between initial and repeat colonoscopy (months), n (%) 0-3 4-6 7-12 ⬎12
61
ⴞ9
65 37 25
(51) (29) (20)
63 64 6
(50) (50) ⫾5
40 36 26 25
(32) (28) (20) (20)
Su1446 Endoscopic Submucosal Dissection (ESD) Versus Transanal Endoscopic Microsurgery (TEM) for the Treatment of Early Rectal Cancer Fabio S. Kawaguti*1, Caio Sergio R. Nahas2, Carlos Frederico S. Marques2, Bruno C. Martins1, Felipe A. Retes1, Marcelo S. Lima1, Cezar F. Sato1, Raphael S. De Medeiros3, Sergio C. Nahas2, Paulo Sakai4, Fauze Maluf-Filho1 1 Endoscopy Division, Cancer Institute of São Paulo University Medical School, São Paulo, Brazil; 2Oncologic Gastrointestinal Surgery Division, Cancer Institute of São Paulo University Medical School, São Paulo, Brazil; 3Pathology Division, Cancer Institute of São Paulo University Medical School, São Paulo, Brazil; 4Unit of Endoscopy, Clinics Hospital of São Paulo University Medical School, São Paulo, Brazil Introduction: Endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) are minimally invasive procedures that can be used to treat early rectal cancer (large rectal adenomas, intramucosal cancers and superficial submucosal cancers). The purpose of this study was to compare clinical efficacy between ESD and TEM for the treatment of early rectal cancer. Methods: Between July 2008 and August 2011, 22 patients with early rectal cancers were treated by ESD (10) or TEM (12) at Cancer Institute of São Paulo University Medical School (São Paulo, Brazil). Data was analyzed retrospectively according to database and pathological reports, with respect to en-bloc resection rate, resection margins, local recurrence, early complications (30 days), histological
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GASTROINTESTINAL ENDOSCOPY
AB334
Abstracts
diagnosis, procedure time and length of hospital stay in both groups. Results: Mean tumor size was 64mm in ESD group and 45mm in TEM group (p⫽0,36). En-bloc resection rates with free margins were achieved in 80% (8/10) in ESD group and 83% (10/12) in TEM group (p⫽0,53). There was only one case of local recurrence in this study, observed in TEM group, 15 months after the index procedure. Postoperative complications in ESD group were two rectal perforations with pneumothorax and subcutaneous emphysema both managed conservatively, and one case of post-polypectomy syndrome. In the TEM group one patient presented temporary fecal incontinence and difficult defecation (130 mm size adenoma). Histological diagnosis showed 1 adenoma, 8 intramucosal cancer and 1 carcinoid tumor invading superficially the submucosa in ESD group. The TEM group showed 4 adenomas, 7 intramucosal cancers and 1 superficial submucosal cancer. In ESD group the mean procedure time was 133 min and in TEM group, 150 min (p⫽0,69). Mean hospital stay was 3,8 days in ESD group and 4,1 days in TEM group (p⫽0,81). Conclusion: Both techniques present good efficacy for the treatment of early rectal cancer, with similar enbloc complete resection rates. In ESD group, there was a higher rate of complications, probably related to the long learning curve of this particular endoscopic procedure.
Su1447 Colorectal Surveillance Interval Assignment Based on In-Vivo Prediction of Polyp Histology: Impact of Endoscopic Quality Improvement Program Susan G. Coe*1, Colleen S. Thomas2, Julia Crook2, Nancy Diehl2, Michael B. Wallace1 1 Gastroenterology, Mayo Clinic, Jacksonville, FL; 2Biostatistics, Mayo Clinic, Jacksonville, FL Introduction: In-vivo predictions of polyp histology, without pathological confirmation, (“resect and discard” or “diagnose and leave behind” strategies) has been proposed as a strategy to reduce health care costs associated with CRC prevention. Recent ASGE guidelines mandate a high level of accuracy for in vivo triage compared to standard pathologic prediction of post-polypectomy surveillance intervals. We hypothesized that an endoscopist training intervention would result in improvement in post-polypectomy surveillance prediction. Methods: As part of a larger prospective randomized study on endoscopist training in colonoscopy, endoscopists were asked to predict the histopathology of all resected polyps during routine colonoscopy and to assign colon cancer surveillance intervals using consensus guidelines. Data were prospectively collected for consecutive outpatient colonoscopies between 8/2 and 04/11/2011, including procedure indication, demographics and risk factors, polyp description, endoscopist prediction of histopathology and actual histopathology. Procedures were excluded if incomplete, had poor bowel prep (BBPS ⬍5), or had an indication of post-cancer surveillance, inflammatory bowel disease, hereditary syndrome surveillance, newly found cancer or active gastrointestinal hemorrhage. Polyps ⱖ10mm were considered “neoplastic” for the purposes of surveillance interval assignment. Comparisons of surveillance interval prediction accuracies were made for each group of study endoscopists (trained and not trained) before (Phase I) and after (Phase II) the training intervention period. Results: Of the 2400 colonoscopies, 1231 patients were found to have polyps. In the group of endoscopists who did not receive training, “optically predicted” surveillance intervals based solely on number of predicted adenomas and size of the largest polyp (independent of risk factors) had an overall accuracy of 81% (236/290) in Phase I and 79% in Phase II (265/337). The group that received training had an overall accuracy of 84% (242/287) in Phase I (prior to training) and 82% (261/317) in Phase II (after training). There was little evidence to suggest that training had a direct, detectable impact on the accuracy of optically predicted surveillance intervals (OR: 1.20, 95% CI: 0.76-1.89, P⫽0.44). When individual patient risk factors were considered the results were similar. Conclusion: Baseline accuracy for optical predication of surveillance intervals is modest. Endoscopist training did not result in improvement of “opticallypredicted” surveillance interval accuracy. These findings highlight the likely need for further studies on methods to train endoscopists to accurately predict polyp histology. Accuracy of optically predicted vs. pathology determined surveillance intervals (no training group) based on # of adenomas and size of largest polyp Phase I
No Training
Accuracy of optically predicted vs. pathology determined surveillance intervals (training group) based on # of adenomas and size of largest polyp Phase I
Training
Pathology determined interval 10 yrs
5 yrs
10yrs 5yrs 3yrs 3mth–1yr
43 44 1 0
26 103 8 2
3 3mthyrs 1yr
10 yrs
5 yrs
3 yrs
3mth1yr
1 3 42 2
10 yrs 5 yrs 3 yrs 3mth – 1yr
39 60 4 1
14 120 13 1
0 0 59 8
0 0 1 17
0 0 0 15
Phase I Accuracy: 70.0% (203/290) Phase II Accuracy: 69.7% (235/337) Bold indicates agreement.
Pathology determined interval
10 yrs
5 yrs
3 3mnthyrs 1yr
Optically predicted interval
10 yrs
5 yrs
3 yrs
3mnth1yr
48 30 3 0
21 107 4 4
0 4 44 4
10 yrs 5 yrs 3 yrs 3mnth-1yr
41 47 3 0
17 130 14 1
0 2 45 6
0 0 0 11
0 1 1 16
Phase I accuracy: 74.9% (215/287) Phase II accuracy: 71.6% (227/317) Bold indicates agreement.
Su1448 Relationship of Non-Alcoholic Fatty Liver Disease to Colorectal Neoplasia Jue Yong Lee*, Ja Won Kim, Sun Pil Choi, Jong Ho Park, Yeon Ho Joo Division of Gastroenterology, Changwon Fatima Hosp, Changwon, Republic of Korea Background and Aims: Metabolic syndrome is associated with an increased risk for colorectal cancer. Non-alcoholic fatty liver disease (NAFLD) is regarded as a hepatic manifestation of metabolic syndrome. Increased echogenicity suggesting NAFLD is a frequent incidental finding on ultrasound examination. In this study, we aimed to determine whether NAFLD has a relationship to colorectal neoplasia. Methods: A consecutive series of 1938 individuals who underwent screening colonoscopy at Changwon Fatima Hospital as part of their employer provided wellness program between Jan. 2009 and Sept. 2011 were reviewed. We divided the 1938 individuals into the adenoma group (n ⫽ 494) and the control group (n ⫽ 1444). Advanced neoplasia was defined as tubular adenoma measuring 1cm or larger, any villous histology, high grade dysplasia, or cancer. Excluded were those individuals with previous history of any malignancy or colorectal adenoma, family history of colorectal neoplasia (including adenomatous polyp), viral hepatitis, and those who drink moderately (alcohol consumption ⬎ 20 g/day). NAFLD was diagnosed by increased echogenicity on abdominal ultrasound. Results: The prevalence of NAFLD was 171 (34.6%) in the adenoma group and 336 (23.3%) in the control group. Compared with normal subjects, the adenoma group subjects were more likely to be men, had an older age, higher BMI, blood pressure, waist circumference, fasting glucose, uric acid, total cholesterol, triglyceride, HbA1c, Hb and ␥GT levels, and a higher prevalence of NAFLD, metabolic syndrome, diabetes mellitus, and hypertension (Table 1). From the multiple logistic regression analysis, older age (ⱖ 50 years), male sex, and prevalence of NAFLD were associated with an increased risk (OR, 2.046; 95% CI, 1.644-2.548; p ⬍ 0.001, OR, 2.395; 95% CI, 1.835-3.125; p ⬍ 0.001, and OR, 1.302; 95% CI, 1.022-1.659; p ⫽ 0.033, respectively) (Table 2). Conclusion: NAFLD is associated with a high prevalence of colorectal neoplasia. Colorectal cancer screening is strongly suggested in those individuals who detected fatty liver on abdominal ultrasound. Table 2. Univariate and multivariate analysis of the risk for colorectal neoplasia by age, gender, NAFLD, metabolic syndrome, hypertension, and diabetes mellitus Control group Adenoma group n ⴝ 1444 (74.5%) n ⴝ 494 (25.5%) ⬍50 ⭌50
1019 (71%) 425 (29%)
Female Male
510 (35%) 934 (65%)
No Yes
1108 (77%) 336 (23%)
No Yes
1218 (91%) 121 (9%)
No Yes
1182 (82%) 262 (18%)
No Yes
1386 (96%) 57 (4%)
Pathology determined interval
Optically predicted interval
Optically predicted interval 10 yrs 5 yrs 3 yrs 3mnth1yr
Phase II
Optically predicted interval
Phase II Pathology determined interval
Univariate analysis OR (95% CI)
Multivariate analysis
p
OR (95% CI)
p
Age (years) 262 (53%) 1 1 232 (47%) 2.123 (1.721–2.619) ⬍0.001 2.046 (1.644–2.548) ⬍0.001 Gender 87 (18%) 1 1 407 (82%) 2.558 (1.980–3.300) ⬍0.001 2.395 (1.835–3.125) ⬍0.001 NAFLD 323 (65%) 1 1 171 (35%) 1.746 (1.398–2.180) ⬍0.001 1.302 (1.022–1.659) 0.033 Metabolic syndrome 377 (77%) 1 1 114 (23%) 1.667 (1.293–2.148) ⬍0.001 1.246 (0.937–1.659) 0.131 Hypertension 369 (75%) 1 1 125 (25%) 1.528 (1.199–1.949) 0.002 1.130 (0.868–1.471) 0.365 Diabetes mellitus 458 (93%) 1 1 36 (7%) 1.911 (1.243–2.939) 0.005 1.249 (0.790–1.977) 0.341
CI, confidence interval; NAFLD, non-alcoholic fatty liver disease; OR, odds ratio.
AB335 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
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