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Su1513 Argon Plasma Coagulation Treatment of Hemorrhagic Radiation Proctopathy: The Safety, Effectiveness, and Long-Term Outcomes
Abstracts
specimen bottle. The primary outcomes of this study (adenoma detection rates) are reported separately. Current results are computed by conducting a post hoc analysis using the Fisher’s exact test and an unpaired t test. Results: 427 patients were prospectively enrolled (7 exclusions, 210 completed study in each arm, mean age 61 years, 95% male, 75% Caucasian, 67% screening colonoscopies). There were no significant differences in age, gender, race, smoking history, BMI, quality of bowel prep, number of screening procedures or withdrawal times between the 2 groups. The proportion of patients with 3 or more adenomas, an adenoma ⱖ 1cm, an adenoma with villous features or HGD, and recommended surveillance intervals are shown in the table. Conclusion: Use of CAC resulted in a significantly higher number of patients being recommended a 3 year follow up surveillance colonoscopy compared to SC. This was the due to a significantly higher detection rate of patients with three or more adenomas and adenomas ⱖ 1cm by CAC. This significant impact of CAC on surveillance interval needs to be confirmed by additional studies.
3 or more Adenomas Adenoma ⱖ1cm Adenoma with Villous features or HGD Surveillance Interval Recommendations 3 year follow up 5 year follow up 10 year follow up
SC N ⴝ 210
CAC N ⴝ 210
P value
38 (18.1%) 39 (18.5%) 5 (2.4%)
62 (29.5%) 76 (36.1%) 10 (4.8%)
0.008 0.0467 0.218 0.039
50 (23.8%) 72 (34.3%) 88 (41.9%)
70 (33.3%) 74 (35.2%) 66 (31.4%)
Su1511 Diagnosis of Colorectal Lesions With a Novel Endocytoscopic Classification - A Pilot Study Shin-Ei Kudo1, Yuichi Mori1, Nobunao Ikehara1, Makoto Kutsukawa1, Kunihiko Wakamura1, Yoshiki Wada1, Hideyuki Miyachi1, Fuyuhiko Yamamura1, Kazuo Ohtsuka1, Shigeharu Hamatani2 1 Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan; 2Division of Pathology, Showa University Northern Yokohama Hospital, Yokohama, Japan. Background & Study Aims: We have previously reported some studies on endocytoscopy (EC), a novel device with ultra-high magnification power (450x) which enables to observe not only structural atypia but also cellular atypia in gastrointestinal tract. EC images in the colorectum are grouped into 5 classes in our novel EC classification; EC1a, EC1b, EC2, EC3a, EC3b. The aim of this pilot prospective study was to evaluate the usefulness of our EC classification of the colorectal lesions compared to the final histopathological findings. Patients & Methods: A total of 257 consecutive patients were enrolled in the study and underwent endocytoscopic examination at the Digestive Disease Center of Showa University Northern Yokohama Hospital from May 2005 to July 2010. Both conventional endoscopic images and endocytoscopic images were stored electronically and only endocytoscopic images were randomly allocated to two blinded readers. They diagnosed them using our proposed EC classification and EC diagnoses were compared with the final histopathological diagnoses. Results: Clear EC images could not be obtained in 10 patients with 10 lesions due to excessive overlying mucus. Thus, 247 patients with 268 specimens (96.4%) were available for analysis. All normal mucosae showed EC1a and all hyperplastic polyps showed EC1b. EC classification of dysplasias was mainly EC2 (83.3%; 130/156), while that of massively invasive submucosal cancers (SMm) or more advanced, which have possibility of metastasis, was mailnly EC3b (89.7%; 78/87). Considering that EC1b was diagnostic for hyperplastic polyps, we could differentiate neoplastic lesions from non-neoplastic lesions with a sensitivity of 100 % and a specificity of 100 % (P⬍0.05). Considering EC3b was diagnostic for SMm or more advanced, we could differentiate ”SMm or more advanced” from other neoplastic lesions (dysplasias and slightly invasive submucosal cancers) with a sensitivity of 89.7 % and a specificity of 99.4% (P⬍0.05). Conclusions: EC was particularly useful for the differentiation between neoplastic and nonneoplastic lesions and between ”SMm or more advanced” and other neoplastic lesions, thus helping on the decision of colorectal neoplasm treatment.
Su1512 Comparison of Carbon Dioxide (CO2) to Air Insufflation in Colonoscopy Rajeswari Ramaraj, Arjun Sugumaran, Hamid Khan, Thiriloganathan Mathialahan, T Paulose George Gastroenterology, Wrexham Maelor hospital, North East Wales, Wrexham, United Kingdom Introduction: It is well known that CO2 insufflation reduces pain during and after colonoscopy. However air insufflation is more popular probably due to limited randomized studies. This study compares the effects of air and CO2
insufflation on pain during and after colonoscopy. Methods: The study was conducted over a 3-month period and 126 patients were randomly assigned into CO2 or air insufflation groups. Discomfort scores during and after colonoscopy was recorded using the modified gloucester discomfort score and factors influencing outcome such as sex, endoscopist grade, previous surgery and sedation were also considered. Results: Of 126 in the study, air was used in 36 and CO2 in 90.The caecal intubation rate in CO2 was 95 vs.91% in the air group. Patients in the CO2 group had lower pain scores during the procedure compared to air. During the procedure, 51.6% CO2 vs.36.11% (Air) had no discomfort at all (score 1). Patients who had a score of 2,3 were 46 Air vs.40% CO2. There was a higher pain score (4,5) noted at 7 vs. 2.7% (Air) noted mainly in females (83.3%). Post procedure discomfort scores were almost equal noted to be 1.19 Air vs.1.06 at 1 hr and 1.08 vs.1.00 CO2 at 2 hrs. A number of factors were taken into consideration to see whether this influenced discomfort scores.1.Sex: 57 males and 69 females were in the study. Females had higher pain scores 31.34 vs.15.52% (males). However this was not statistically significant using the MannWhitney test.2.Sedation: Average sedation used, midazolam 1.93 vs.0.67mg CO2, Pethidine 9 vs.14mg(CO2), fentanyl 34 vs.17mg CO2. Average top up sedation used was 0.02 vs. 0.05 mg CO2 of midazolam, Pethidine 0.69 vs.0.5mg CO2 and fentanyl 2.5mg top up for CO2 group versus no top up.3.Previous surgery:Data for only 74 patients was available. Those patients who have had no previous surgery (n⫽50) appear to have lower discomfort levels, however data points for pelvic surgery were too few to come to a conclusion.4.Endoscopist: Discomfort scores were higher in trainees (n⫽34) using CO2 than consultants (n⫽56). Using Mann-Whitney test this was statistically significant with a CI of 95.1%. There was no difference in scores in air group. In the consultant group, using CO2 lowered patient discomfort compared to air (P 0.06) that was statistically significant. Conclusion: Though CO2 insufflation is said to be effective in reducing post procedural discomfort there was not much difference in both groups in our study however pain was reduced during procedure in the C02 group.Caecal intubation rate was slightly higher in the CO2 group and endoscopist grade and no previous surgery influenced comfort outcome in favour of C02.
Air C02
Top up (in mg)
Midazolam (mg)
Pethidine (mg)
Fentanyl (mg)
Midazolam
Pethidine
Fentanyl
1.93 0.67
9.0 14
34 17
0.02 0.05
0.69 0.5
0 2.5
Sedation required during colonoscopy represented in Air and Carbon dioxide groups.
Su1513 Argon Plasma Coagulation Treatment of Hemorrhagic Radiation Proctopathy: The Safety, Effectiveness, and Long-Term Outcomes Yasushi Sato1, Tamotsu Sagawa1, Hiroyuki Ohnuma1, Masahiro Hirakawa1, Koji Miyanishi1, Tsutomu Sato1, Masayoshi Kobune1, Rishu Takimoto1, Tetsuji Takayama2, Junji Kato1 1 Fourth Department of Internal Medicine, Sapporo Medical University, School of Medicine, Sapporo, Japan; 2Department of Gastroenterology and Oncology, Tokushima University, Tokushima, Japan Background and aim: Recently it has been reported that argon plasma coagulation (APC) is effective for hemorrhagic radiation proctopathy (HRP). However, previous studies documented complications such as ulcer, stricture and perforation in up to 20% of APC-treated patients and the long-term effects of APC treatment remains unknown. The aim of this study was to assess the safety, effectiveness, and long-term outcomes of APC in HRP patients. Methods: APC treatment was administered using a single-channel flexible colonoscope (Olympus CF-Q240AI). Treatment was performed using the ERBE system (Tuebingen, Germany), consisting of an argon source APC 300, a high-frequency electrosurgical generator ICC 200, and axial spot-beam probes, at the following settings: power 40W, single pulses up to 2 seconds, and gas flow of 1.2 L/min. APC was performed at 1- or 2-week intervals until all visible telangiectatic lesions had been eliminated. The endoscopic score for HRP was graded from A to C, according to the endoscopic scoring system reported by Zinicola et al. The severity of rectal bleeding before and after treatment was graded from 0 to 4, according to the bleeding scoring system reported by Chutkan et al. Results: Seventy patients (M/F, 50/20; median age, 75) with HRP occurring at a mean of 23 months after radiotherapy were studied. Proctopathy was classified as grade A (mild) in 8 patients (11.4 %), grade B (moderate) in 44 (62.9 %), and grade C (severe) in 18 (25.7 %). The treatment success rate was 98.6% after a median of 2 (range 1-5) APC sessions. The median clinical score for rectal bleeding was significantly deceased after APC (p ⬍0.0001) and the hemoglobin level was significantly increased (p ⬍0.0001). APC was well tolerated and no significant side effects or complications occurred. During a mean follow-up of 35.2 months (range 4 -127), 4 patients (5.8 %) showed minor recurrent rectal bleeding and 60 (92.9 %) remained in remission. Conclusions: Our patient series represents one of the largest reported to date for the treatment of HRP and demonstrate longlasting effects of APC, persisting up to 10 years. APC is an easy to use, safe, effective, and well-tolerated treatment, and should be proposed as a first-line treatment.
AB288 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
specimen bottle. The primary outcomes of this study (adenoma detection rates) are reported separately. Current results are computed by conducting a post hoc analysis using the Fisher’s exact test and an unpaired t test. Results: 427 patients were prospectively enrolled (7 exclusions, 210 completed study in each arm, mean age 61 years, 95% male, 75% Caucasian, 67% screening colonoscopies). There were no significant differences in age, gender, race, smoking history, BMI, quality of bowel prep, number of screening procedures or withdrawal times between the 2 groups. The proportion of patients with 3 or more adenomas, an adenoma ⱖ 1cm, an adenoma with villous features or HGD, and recommended surveillance intervals are shown in the table. Conclusion: Use of CAC resulted in a significantly higher number of patients being recommended a 3 year follow up surveillance colonoscopy compared to SC. This was the due to a significantly higher detection rate of patients with three or more adenomas and adenomas ⱖ 1cm by CAC. This significant impact of CAC on surveillance interval needs to be confirmed by additional studies.
3 or more Adenomas Adenoma ⱖ1cm Adenoma with Villous features or HGD Surveillance Interval Recommendations 3 year follow up 5 year follow up 10 year follow up
SC N ⴝ 210
CAC N ⴝ 210
P value
38 (18.1%) 39 (18.5%) 5 (2.4%)
62 (29.5%) 76 (36.1%) 10 (4.8%)
0.008 0.0467 0.218 0.039
50 (23.8%) 72 (34.3%) 88 (41.9%)
70 (33.3%) 74 (35.2%) 66 (31.4%)
Su1511 Diagnosis of Colorectal Lesions With a Novel Endocytoscopic Classification - A Pilot Study Shin-Ei Kudo1, Yuichi Mori1, Nobunao Ikehara1, Makoto Kutsukawa1, Kunihiko Wakamura1, Yoshiki Wada1, Hideyuki Miyachi1, Fuyuhiko Yamamura1, Kazuo Ohtsuka1, Shigeharu Hamatani2 1 Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan; 2Division of Pathology, Showa University Northern Yokohama Hospital, Yokohama, Japan. Background & Study Aims: We have previously reported some studies on endocytoscopy (EC), a novel device with ultra-high magnification power (450x) which enables to observe not only structural atypia but also cellular atypia in gastrointestinal tract. EC images in the colorectum are grouped into 5 classes in our novel EC classification; EC1a, EC1b, EC2, EC3a, EC3b. The aim of this pilot prospective study was to evaluate the usefulness of our EC classification of the colorectal lesions compared to the final histopathological findings. Patients & Methods: A total of 257 consecutive patients were enrolled in the study and underwent endocytoscopic examination at the Digestive Disease Center of Showa University Northern Yokohama Hospital from May 2005 to July 2010. Both conventional endoscopic images and endocytoscopic images were stored electronically and only endocytoscopic images were randomly allocated to two blinded readers. They diagnosed them using our proposed EC classification and EC diagnoses were compared with the final histopathological diagnoses. Results: Clear EC images could not be obtained in 10 patients with 10 lesions due to excessive overlying mucus. Thus, 247 patients with 268 specimens (96.4%) were available for analysis. All normal mucosae showed EC1a and all hyperplastic polyps showed EC1b. EC classification of dysplasias was mainly EC2 (83.3%; 130/156), while that of massively invasive submucosal cancers (SMm) or more advanced, which have possibility of metastasis, was mailnly EC3b (89.7%; 78/87). Considering that EC1b was diagnostic for hyperplastic polyps, we could differentiate neoplastic lesions from non-neoplastic lesions with a sensitivity of 100 % and a specificity of 100 % (P⬍0.05). Considering EC3b was diagnostic for SMm or more advanced, we could differentiate ”SMm or more advanced” from other neoplastic lesions (dysplasias and slightly invasive submucosal cancers) with a sensitivity of 89.7 % and a specificity of 99.4% (P⬍0.05). Conclusions: EC was particularly useful for the differentiation between neoplastic and nonneoplastic lesions and between ”SMm or more advanced” and other neoplastic lesions, thus helping on the decision of colorectal neoplasm treatment.
Su1512 Comparison of Carbon Dioxide (CO2) to Air Insufflation in Colonoscopy Rajeswari Ramaraj, Arjun Sugumaran, Hamid Khan, Thiriloganathan Mathialahan, T Paulose George Gastroenterology, Wrexham Maelor hospital, North East Wales, Wrexham, United Kingdom Introduction: It is well known that CO2 insufflation reduces pain during and after colonoscopy. However air insufflation is more popular probably due to limited randomized studies. This study compares the effects of air and CO2
insufflation on pain during and after colonoscopy. Methods: The study was conducted over a 3-month period and 126 patients were randomly assigned into CO2 or air insufflation groups. Discomfort scores during and after colonoscopy was recorded using the modified gloucester discomfort score and factors influencing outcome such as sex, endoscopist grade, previous surgery and sedation were also considered. Results: Of 126 in the study, air was used in 36 and CO2 in 90.The caecal intubation rate in CO2 was 95 vs.91% in the air group. Patients in the CO2 group had lower pain scores during the procedure compared to air. During the procedure, 51.6% CO2 vs.36.11% (Air) had no discomfort at all (score 1). Patients who had a score of 2,3 were 46 Air vs.40% CO2. There was a higher pain score (4,5) noted at 7 vs. 2.7% (Air) noted mainly in females (83.3%). Post procedure discomfort scores were almost equal noted to be 1.19 Air vs.1.06 at 1 hr and 1.08 vs.1.00 CO2 at 2 hrs. A number of factors were taken into consideration to see whether this influenced discomfort scores.1.Sex: 57 males and 69 females were in the study. Females had higher pain scores 31.34 vs.15.52% (males). However this was not statistically significant using the MannWhitney test.2.Sedation: Average sedation used, midazolam 1.93 vs.0.67mg CO2, Pethidine 9 vs.14mg(CO2), fentanyl 34 vs.17mg CO2. Average top up sedation used was 0.02 vs. 0.05 mg CO2 of midazolam, Pethidine 0.69 vs.0.5mg CO2 and fentanyl 2.5mg top up for CO2 group versus no top up.3.Previous surgery:Data for only 74 patients was available. Those patients who have had no previous surgery (n⫽50) appear to have lower discomfort levels, however data points for pelvic surgery were too few to come to a conclusion.4.Endoscopist: Discomfort scores were higher in trainees (n⫽34) using CO2 than consultants (n⫽56). Using Mann-Whitney test this was statistically significant with a CI of 95.1%. There was no difference in scores in air group. In the consultant group, using CO2 lowered patient discomfort compared to air (P 0.06) that was statistically significant. Conclusion: Though CO2 insufflation is said to be effective in reducing post procedural discomfort there was not much difference in both groups in our study however pain was reduced during procedure in the C02 group.Caecal intubation rate was slightly higher in the CO2 group and endoscopist grade and no previous surgery influenced comfort outcome in favour of C02.
Air C02
Top up (in mg)
Midazolam (mg)
Pethidine (mg)
Fentanyl (mg)
Midazolam
Pethidine
Fentanyl
1.93 0.67
9.0 14
34 17
0.02 0.05
0.69 0.5
0 2.5
Sedation required during colonoscopy represented in Air and Carbon dioxide groups.
Su1513 Argon Plasma Coagulation Treatment of Hemorrhagic Radiation Proctopathy: The Safety, Effectiveness, and Long-Term Outcomes Yasushi Sato1, Tamotsu Sagawa1, Hiroyuki Ohnuma1, Masahiro Hirakawa1, Koji Miyanishi1, Tsutomu Sato1, Masayoshi Kobune1, Rishu Takimoto1, Tetsuji Takayama2, Junji Kato1 1 Fourth Department of Internal Medicine, Sapporo Medical University, School of Medicine, Sapporo, Japan; 2Department of Gastroenterology and Oncology, Tokushima University, Tokushima, Japan Background and aim: Recently it has been reported that argon plasma coagulation (APC) is effective for hemorrhagic radiation proctopathy (HRP). However, previous studies documented complications such as ulcer, stricture and perforation in up to 20% of APC-treated patients and the long-term effects of APC treatment remains unknown. The aim of this study was to assess the safety, effectiveness, and long-term outcomes of APC in HRP patients. Methods: APC treatment was administered using a single-channel flexible colonoscope (Olympus CF-Q240AI). Treatment was performed using the ERBE system (Tuebingen, Germany), consisting of an argon source APC 300, a high-frequency electrosurgical generator ICC 200, and axial spot-beam probes, at the following settings: power 40W, single pulses up to 2 seconds, and gas flow of 1.2 L/min. APC was performed at 1- or 2-week intervals until all visible telangiectatic lesions had been eliminated. The endoscopic score for HRP was graded from A to C, according to the endoscopic scoring system reported by Zinicola et al. The severity of rectal bleeding before and after treatment was graded from 0 to 4, according to the bleeding scoring system reported by Chutkan et al. Results: Seventy patients (M/F, 50/20; median age, 75) with HRP occurring at a mean of 23 months after radiotherapy were studied. Proctopathy was classified as grade A (mild) in 8 patients (11.4 %), grade B (moderate) in 44 (62.9 %), and grade C (severe) in 18 (25.7 %). The treatment success rate was 98.6% after a median of 2 (range 1-5) APC sessions. The median clinical score for rectal bleeding was significantly deceased after APC (p ⬍0.0001) and the hemoglobin level was significantly increased (p ⬍0.0001). APC was well tolerated and no significant side effects or complications occurred. During a mean follow-up of 35.2 months (range 4 -127), 4 patients (5.8 %) showed minor recurrent rectal bleeding and 60 (92.9 %) remained in remission. Conclusions: Our patient series represents one of the largest reported to date for the treatment of HRP and demonstrate longlasting effects of APC, persisting up to 10 years. APC is an easy to use, safe, effective, and well-tolerated treatment, and should be proposed as a first-line treatment.
AB288 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org