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Su1691 The management for colorectal diminutive adenomatous polyps using pit pattern classification with magnifying chromoendoscopy
Abstracts
Su1690 Underwater Endoscopic Mucosal Resection (EMR) Shows a Higher Single Session Curative Resection Rate Than Conventional EMR Technique: A Single Center Experience Mitchell L. Liverant*1, Benjamin Yip2, Nathan Kwak2, Shawn Kaye2, Marielle Reataza1, John G. Lee1, Kenneth J. Chang1, Jason B. Samarasena1 1 Gastroenterology, University of California - Irvine, Long Beach, CA; 2 Internal Medicine, University of California - Irvine, Orange, CA Background: Endoscopic mucosal resection (EMR) involving submucosal injection to lift and remove large and sessile colorectal polyps is the current standard of care. Underwater EMR (UW-EMR) involves complete water immersion of polyps and snare resection without submucosal injection. A few small studies have shown this technique to be effective in large polyp removal with minimal training and short learning curve. Data comparing this technique to standard EMR (S-EMR) is lacking. This study aimed to further validate the success and safety of this novel endoscopic technique for polyp removal in comparison to S-EMR. Methods: We performed a retrospective review of UW-EMR procedures performed by a single endoscopist at a tertiary care center over a 2-year period and compared these to S-EMR procedures performed over the same time period. The primary outcomes studied were 1) technical success of UW-EMR ,defined as complete resection without conventional saline injection, 2) safety based on adverse events, immediate (<24 hours) and delayed (>24 hours). Secondary outcomes included single session curative resection rate, defined as en bloc resection with clear histologic margins or piecemeal resection with no histologic evidence of residual polyp on follow up colonoscopy. UW-EMR polypectomy time was also evaluated. Results: In the UW-EMR group there were 32 patients (18 males, mean age 63.8 years) with 39 polyps resected. Mean polyp size 27.5 mm (range 6-50mm). In the S-EMR group, there were 39 patients (17 male, mean age 63.4 years) with 48 polyps resected. Mean polyp size 17.2 mm (range 2-60mm). Technical success rate of UW-EMR was 100% with no polyps requiring reversion to S-EMR technique. In the UW-EMR group there were 2 cases (6.3%) of delayed hematochezia requiring repeat colonoscopy and hemostasis. There was 1 case of abdominal pain requiring hospitalization and 1 case of delayed hematochezia (5%) in the S-EMR group. No perforations or other adverse events were noted. 23 of the 39 polyps in the UW-EMR group and 47 of the 48 polyps in the standard EMR group were resected en bloc or underwent repeat colonoscopy to assess EMR site. Single session curative resection rate for UW-EMR was 100% vs 74% in the SEMR group (pZ0.007). On video review, mean time for an UW-EMR polypectomy was 13 minutes, 36 seconds. Conclusions: This study supports the existing literature demonstrating excellent rates of technical success and safety with UW-EMR. Our study shows a large and significant difference in single session curative resection rates of UW-EMR over current S-EMR technique, with no residual polyp detected histologically on follow-up evaluation for all polyps that underwent UW-EMR technique. Validation of these promising results in a randomized controlled trial is currently underway.
Polyp characteristics and complications Polyp characteristics Polyps, n. Polyp size, mm avg (range) Polyp location (%) Right colon Transverse colon Left colon Pathology (%) Tubular adenoma Tubulovillous adenoma Sessile serrated adenoma/polyp Adenocarcinoma Adverse events (%) Immediate Delayed En bloc (% of total polyps) Residual polyp at EMR site (EMR sites examined) Single Session Curative Resection Rate
Standard EMR
Underwater
48 17.2 (2-60)
39 27.5 (6-50)
22 (46) 9 (19) 17 (35)
25 (64) 5 (13) 9 (23)
29 (60) 11 (23) 7 (15) 1 (2)
25 (68) 6 (16) 5 (14) 1 (2)
1 (2.5) 1 (2.5) 13 (27.1) 12 (34)
0 (0) 2 (6) 8 (20.5) 0 (15)
74% (35/47)
100% (23/23)
p-value 0.0002 0.235
0.499
0.007
Su1691 The management for colorectal diminutive adenomatous polyps using pit pattern classification with magnifying chromoendoscopy Yasuharu Maeda*, Shin-ei Kudo, Kunihiko Wakamura, Hideyuki Miyachi, Seiko Hayashi, Masashi Misawa, Yuichi Mori, Toyoki Kudo, Takemasa Hayashi, Atsushi Katagiri, Fumio Ishida Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa, Japan
www.giejournal.org
Background: It is now available to estimate histological feature of colorectal lesions using magnifying chromo-endoscopy (pit pattern (PIT) classification). In regard to diminutive (&5mm) adenomatous polyps (DAPs), it has been reported that the prevalence of advanced histological features was low. However diminutive invasive cancer has been found. Currently, some endoscopists in Japan leave DAPs unresected after detailed observation and close follow-up. This is because they consider that polypectomy may be unnecessary due to the low prevalence of advanced features in these polyps, and it may be unnecessary to expose patients to added risks during colonoscopy1). In our center, DAPs with type IIIL PIT are left untreated, while lesions with type III, IV, or IV PIT are resected by routine colonoscopy. Metheod: The aim of this retrospective study was to assess our management DAPs using PIT classification. The study subjects were patients over 30 years who were referred for initial total colonoscopy were followed up for more than 3 years between April 2001 and March 2014. Exclusion criteria was patients who had the lesions >5mm in size and/or with type IIIs, IV or V PIT left untreated at initial treatment, and those who have a history of familial adenomatous polyposis, Lynch syndrome, Advanced colorectal cancer, Inflammatory bowel disease and cololectomy.They were classified into three groups according to the findings and treatment of initial colonoscopy: Group A, patients whose DAPs with type IIIL PIT were left untreated as semi-clean colon group; Group B, patients whose all neoplastic polyps including DAPs were resected as clean colon group; Group C, patients without any adenomatous polyp as internal control group. As a primary outcome measure, the cumulative incidence of index lesions (ILs) at follow-up colonoscopy analyzed among the three groups. The ILs diagnosed during follow-up colonoscopy was defined as follows: large adenomatous polyp S10 mm, high grade dysplasia (intra mucosal cancer), and invasive cancer. We evaluation the incidences of invasive cancers. Result: A total of 4602 patients were enrolled in our study. 1439 patients classified into Group A, 1112 in Group B, 2051 in Group C. ILs were detected in 136 patients (9.4%) in Group A, 116 (10.4%) in Group B, and 40 (2.0%) in Group C, respectively. Invasive cancers were detected in 12 patients (0.8%) in Group A, 12 (1.1%) in Group B, and 9 (0.4%) in Group C, respectively. There was no significant difference between Group A and Group B in incidences of ILs and invasive cancer. In regard to Group C, it was significant lower than Group B and Group C in incidences of them. Conclusion: We confirmed that removing type IIIL PIT DAPs did not decrease the incidence of ILs. These polyps may thus be left untreated and observed in follow-up. 1) Matsuda T, et al. Dig Endosc 2014; 26 Suppl 2: 104-108.
Su1692 Adenoma and Sessile Serrated Adenoma Detection Rates in Surveillance Endoscopy Jennifer K. Maratt*1, Philip Schoenfeld1, Grace H. Elta1, Kenya Jackson1, Daniel Rizk2, Christine Jakubiec1, Stacy B. Menees1 1 Gastroenterology, University of Michigan, Ann Arbor, MI; 2University of Michigan, Ann Arbor, MI Background: Adenoma detection rate (ADR) has been used as a quality indicator for screening colonoscopy since 2006. However, data on ADR and sessile serrated adenoma detection rate (SSADR) in surveillance colonoscopy is limited. The purpose of this study was to determine ADR and SSADR in surveillance colonoscopy and to identify predictors. Methods: Retrospective chart review of subjects who had a surveillance colonoscopy for history of polyps from 2014-2015 was performed. Patients 40 to 85 years old with confirmed adenoma or SSA on prior pathology who underwent colonoscopy by a gastroenterologist were included. Subjects were excluded if they had an incomplete exam or any other indication. Patient demographics, endoscopist characteristics, and procedure details were collected. Polyps were defined as nonadvanced if <10mm and advanced if 10mm in size. Chi-square and Student’s t tests were used to determine differences in ADR and SSADR and multivariable logistic regression was used to assess predictors. Results: 1,626 surveillance colonoscopies were reviewed and 1,070 met inclusion criteria. Subjects were 87% Caucasian, 57% male with a mean age of 62.8 (8.3) years (Table 1). 60 endoscopists performed the colonoscopies with an average of 11.7 (9.4) years in practice. 86% of subjects had prior adenomas and 14% had prior SSAs. For surveillance colonoscopy, adenomas were found in 506 patients for ADR 47% (61% in males, 47% in females). 44% of patients had nonadvanced adenomas and 6% had advanced adenomas. Adenomas were most common in the ascending colon/hepatic flexure (41%), followed by transverse colon (37%), cecum (24%), descending/sigmoid colon (19%) and rectum (6%). SSAs were found in 106 patients for SSADR 10% (13% in males, 22% in females). 7.2% of patients had nonadvanced SSAs and 2.2% had advanced SSAs. SSAs were also most common in the ascending colon/hepatic flexure (39%), followed by descending/sigmoid colon (29%), cecum (23%), transverse colon (22%) and rectum (5%). CRC was found in 3 (0.2%) patients. Using multivariable logistic regression, predictors of ADR that were positively associated with adenoma prevalence were increasing age (OR 1.02; 95% CI 1.004-1.038), male gender (OR 1.74; 95% CI 1.33-2.29) and diabetes (OR 1.86; 95% CI 1.26-2.74). For SSADR, male gender was protective against SSAs (OR 0.54; 95% CI 0.35-0.84), whereas Caucasian race (OR 3.90; 95% CI 1.37-11.13) and higher endoscopist ADR (OR 1.04; 95% CI 1.01-1.07) were associated with higher likelihood of SSA. Conclusion: ADR and SSADR on surveillance colonoscopy were found to be 47% and 10%, respectively. Endoscopists with higher screening ADR also had higher SSADR. Male gender was associated with lower odds of SSAs while Caucasian race was
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB397
Su1690 Underwater Endoscopic Mucosal Resection (EMR) Shows a Higher Single Session Curative Resection Rate Than Conventional EMR Technique: A Single Center Experience Mitchell L. Liverant*1, Benjamin Yip2, Nathan Kwak2, Shawn Kaye2, Marielle Reataza1, John G. Lee1, Kenneth J. Chang1, Jason B. Samarasena1 1 Gastroenterology, University of California - Irvine, Long Beach, CA; 2 Internal Medicine, University of California - Irvine, Orange, CA Background: Endoscopic mucosal resection (EMR) involving submucosal injection to lift and remove large and sessile colorectal polyps is the current standard of care. Underwater EMR (UW-EMR) involves complete water immersion of polyps and snare resection without submucosal injection. A few small studies have shown this technique to be effective in large polyp removal with minimal training and short learning curve. Data comparing this technique to standard EMR (S-EMR) is lacking. This study aimed to further validate the success and safety of this novel endoscopic technique for polyp removal in comparison to S-EMR. Methods: We performed a retrospective review of UW-EMR procedures performed by a single endoscopist at a tertiary care center over a 2-year period and compared these to S-EMR procedures performed over the same time period. The primary outcomes studied were 1) technical success of UW-EMR ,defined as complete resection without conventional saline injection, 2) safety based on adverse events, immediate (<24 hours) and delayed (>24 hours). Secondary outcomes included single session curative resection rate, defined as en bloc resection with clear histologic margins or piecemeal resection with no histologic evidence of residual polyp on follow up colonoscopy. UW-EMR polypectomy time was also evaluated. Results: In the UW-EMR group there were 32 patients (18 males, mean age 63.8 years) with 39 polyps resected. Mean polyp size 27.5 mm (range 6-50mm). In the S-EMR group, there were 39 patients (17 male, mean age 63.4 years) with 48 polyps resected. Mean polyp size 17.2 mm (range 2-60mm). Technical success rate of UW-EMR was 100% with no polyps requiring reversion to S-EMR technique. In the UW-EMR group there were 2 cases (6.3%) of delayed hematochezia requiring repeat colonoscopy and hemostasis. There was 1 case of abdominal pain requiring hospitalization and 1 case of delayed hematochezia (5%) in the S-EMR group. No perforations or other adverse events were noted. 23 of the 39 polyps in the UW-EMR group and 47 of the 48 polyps in the standard EMR group were resected en bloc or underwent repeat colonoscopy to assess EMR site. Single session curative resection rate for UW-EMR was 100% vs 74% in the SEMR group (pZ0.007). On video review, mean time for an UW-EMR polypectomy was 13 minutes, 36 seconds. Conclusions: This study supports the existing literature demonstrating excellent rates of technical success and safety with UW-EMR. Our study shows a large and significant difference in single session curative resection rates of UW-EMR over current S-EMR technique, with no residual polyp detected histologically on follow-up evaluation for all polyps that underwent UW-EMR technique. Validation of these promising results in a randomized controlled trial is currently underway.
Polyp characteristics and complications Polyp characteristics Polyps, n. Polyp size, mm avg (range) Polyp location (%) Right colon Transverse colon Left colon Pathology (%) Tubular adenoma Tubulovillous adenoma Sessile serrated adenoma/polyp Adenocarcinoma Adverse events (%) Immediate Delayed En bloc (% of total polyps) Residual polyp at EMR site (EMR sites examined) Single Session Curative Resection Rate
Standard EMR
Underwater
48 17.2 (2-60)
39 27.5 (6-50)
22 (46) 9 (19) 17 (35)
25 (64) 5 (13) 9 (23)
29 (60) 11 (23) 7 (15) 1 (2)
25 (68) 6 (16) 5 (14) 1 (2)
1 (2.5) 1 (2.5) 13 (27.1) 12 (34)
0 (0) 2 (6) 8 (20.5) 0 (15)
74% (35/47)
100% (23/23)
p-value 0.0002 0.235
0.499
0.007
Su1691 The management for colorectal diminutive adenomatous polyps using pit pattern classification with magnifying chromoendoscopy Yasuharu Maeda*, Shin-ei Kudo, Kunihiko Wakamura, Hideyuki Miyachi, Seiko Hayashi, Masashi Misawa, Yuichi Mori, Toyoki Kudo, Takemasa Hayashi, Atsushi Katagiri, Fumio Ishida Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa, Japan
www.giejournal.org
Background: It is now available to estimate histological feature of colorectal lesions using magnifying chromo-endoscopy (pit pattern (PIT) classification). In regard to diminutive (&5mm) adenomatous polyps (DAPs), it has been reported that the prevalence of advanced histological features was low. However diminutive invasive cancer has been found. Currently, some endoscopists in Japan leave DAPs unresected after detailed observation and close follow-up. This is because they consider that polypectomy may be unnecessary due to the low prevalence of advanced features in these polyps, and it may be unnecessary to expose patients to added risks during colonoscopy1). In our center, DAPs with type IIIL PIT are left untreated, while lesions with type III, IV, or IV PIT are resected by routine colonoscopy. Metheod: The aim of this retrospective study was to assess our management DAPs using PIT classification. The study subjects were patients over 30 years who were referred for initial total colonoscopy were followed up for more than 3 years between April 2001 and March 2014. Exclusion criteria was patients who had the lesions >5mm in size and/or with type IIIs, IV or V PIT left untreated at initial treatment, and those who have a history of familial adenomatous polyposis, Lynch syndrome, Advanced colorectal cancer, Inflammatory bowel disease and cololectomy.They were classified into three groups according to the findings and treatment of initial colonoscopy: Group A, patients whose DAPs with type IIIL PIT were left untreated as semi-clean colon group; Group B, patients whose all neoplastic polyps including DAPs were resected as clean colon group; Group C, patients without any adenomatous polyp as internal control group. As a primary outcome measure, the cumulative incidence of index lesions (ILs) at follow-up colonoscopy analyzed among the three groups. The ILs diagnosed during follow-up colonoscopy was defined as follows: large adenomatous polyp S10 mm, high grade dysplasia (intra mucosal cancer), and invasive cancer. We evaluation the incidences of invasive cancers. Result: A total of 4602 patients were enrolled in our study. 1439 patients classified into Group A, 1112 in Group B, 2051 in Group C. ILs were detected in 136 patients (9.4%) in Group A, 116 (10.4%) in Group B, and 40 (2.0%) in Group C, respectively. Invasive cancers were detected in 12 patients (0.8%) in Group A, 12 (1.1%) in Group B, and 9 (0.4%) in Group C, respectively. There was no significant difference between Group A and Group B in incidences of ILs and invasive cancer. In regard to Group C, it was significant lower than Group B and Group C in incidences of them. Conclusion: We confirmed that removing type IIIL PIT DAPs did not decrease the incidence of ILs. These polyps may thus be left untreated and observed in follow-up. 1) Matsuda T, et al. Dig Endosc 2014; 26 Suppl 2: 104-108.
Su1692 Adenoma and Sessile Serrated Adenoma Detection Rates in Surveillance Endoscopy Jennifer K. Maratt*1, Philip Schoenfeld1, Grace H. Elta1, Kenya Jackson1, Daniel Rizk2, Christine Jakubiec1, Stacy B. Menees1 1 Gastroenterology, University of Michigan, Ann Arbor, MI; 2University of Michigan, Ann Arbor, MI Background: Adenoma detection rate (ADR) has been used as a quality indicator for screening colonoscopy since 2006. However, data on ADR and sessile serrated adenoma detection rate (SSADR) in surveillance colonoscopy is limited. The purpose of this study was to determine ADR and SSADR in surveillance colonoscopy and to identify predictors. Methods: Retrospective chart review of subjects who had a surveillance colonoscopy for history of polyps from 2014-2015 was performed. Patients 40 to 85 years old with confirmed adenoma or SSA on prior pathology who underwent colonoscopy by a gastroenterologist were included. Subjects were excluded if they had an incomplete exam or any other indication. Patient demographics, endoscopist characteristics, and procedure details were collected. Polyps were defined as nonadvanced if <10mm and advanced if 10mm in size. Chi-square and Student’s t tests were used to determine differences in ADR and SSADR and multivariable logistic regression was used to assess predictors. Results: 1,626 surveillance colonoscopies were reviewed and 1,070 met inclusion criteria. Subjects were 87% Caucasian, 57% male with a mean age of 62.8 (8.3) years (Table 1). 60 endoscopists performed the colonoscopies with an average of 11.7 (9.4) years in practice. 86% of subjects had prior adenomas and 14% had prior SSAs. For surveillance colonoscopy, adenomas were found in 506 patients for ADR 47% (61% in males, 47% in females). 44% of patients had nonadvanced adenomas and 6% had advanced adenomas. Adenomas were most common in the ascending colon/hepatic flexure (41%), followed by transverse colon (37%), cecum (24%), descending/sigmoid colon (19%) and rectum (6%). SSAs were found in 106 patients for SSADR 10% (13% in males, 22% in females). 7.2% of patients had nonadvanced SSAs and 2.2% had advanced SSAs. SSAs were also most common in the ascending colon/hepatic flexure (39%), followed by descending/sigmoid colon (29%), cecum (23%), transverse colon (22%) and rectum (5%). CRC was found in 3 (0.2%) patients. Using multivariable logistic regression, predictors of ADR that were positively associated with adenoma prevalence were increasing age (OR 1.02; 95% CI 1.004-1.038), male gender (OR 1.74; 95% CI 1.33-2.29) and diabetes (OR 1.86; 95% CI 1.26-2.74). For SSADR, male gender was protective against SSAs (OR 0.54; 95% CI 0.35-0.84), whereas Caucasian race (OR 3.90; 95% CI 1.37-11.13) and higher endoscopist ADR (OR 1.04; 95% CI 1.01-1.07) were associated with higher likelihood of SSA. Conclusion: ADR and SSADR on surveillance colonoscopy were found to be 47% and 10%, respectively. Endoscopists with higher screening ADR also had higher SSADR. Male gender was associated with lower odds of SSAs while Caucasian race was
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB397