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Tu1446 Rectal Location Confers Increased Risk of Colorectal Cancer in Specific Subgroups of Advanced Mucosal Neoplasia
Abstracts
Endoscopic Mucosal Resection Margin and Depth Assessment Scale (EMR-MDA Scale) Nomenclature e p n B B0 B1 E E0 E1 MDA Scale 0 MDA Scale 1 MDA Scale 2
En Bloc resection Piecemeal resection Number of pieces taken during piecemeal resection Base of the resection No neoplastic tissue at resection base-clean base Neoplastic tissue at the resection base Edge of the resection No neoplastic tissue at resection edge; round mucosal pit pattern observed Neoplastic tissue at resection edge EMR MDA Scale eB0E0 (Enbloc resection without residual tissue) p n (ⱕ3)B0E0 (Piecemeal resection, nⱕ3, without residual tissue) p n (⬎3) or B1 or E1 (Piecemeal resection, n⬎3 or residual tissue at base or edge)
Tu1444 Characteristics of Colorectal Muscularis Propria Carcinoma Derived From Depressed- Type Early Lesions Tomokazu Hisayuki*1, Shin-Ei Kudo1, Shigeharu Hamatani2, Hideyuki Miyachi1, Katsuro Ichimasa1, Hiromasa Oikawa1, Yuichi Mori1, Masashi Misawa1, Toyoki Kudo1, Kenta Kodama1, Yoshiki Wada1, Takemasa Hayashi1, Kunihiko Wakamura1, Eiji Hidaka1, Fuyuhiko Yamamura1, Shogo Ohkoshi1, Fumio Ishida1, Jun-Ichi Tanaka1 1 Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan; 2Department of Pathology, Showa University Northern Yokohama Hospital, Yokohama, Japan Backgrounds: The general recognition is that “adenoma-carcinoma sequence” has been considered as the mainstream theory of the development of colorectal cancer. Recently, an increasing number of depressed-type early colorectal cancers are being reported not only in the East but also in the West. Depressedtype early cancers are considered to emerge directly from normal mucosa without going through adenomas and become invasive even when carcinomas as early as they are around 10mm in diameter. Aims: The aim is to clarify the characteristics of colorectal muscularis propria carcinoma derived from depressed-type early lesions. Method: A total of 16200 neoplasms were resected endoscopically or surgically at our unit from April 2001 to April 2009. Of these 195 muscularis propria carcinomas were included. There were 50 lesions(25.6%) with nodal metastasis and 2 lesions(1.0%) with distant metastasis. The lesions were classified into 4 categories based on the endoscopic view: (A) Depressed type (with the periphery consisted of normal mucosa), (B) Laterally spreading type, (C) Protruded type, and (D) Ulcerative type (with the periphery consisted of neoplastic tissue). Category A lesions are the cases which can be estimated to have developed from depressed-type early cancers. We analyzed those lesions in terms of tumor size, lymphatic involvement, venous involvement, nodal metastasis and distant metastasis. Results: The 195 muscularis propria carcinomas were classified as (A) 74 lesions(38.0%), (B) 26 lesions(13.3%), (C) 24 lesions(12.3%), and (D) 71 lesions(36.4%). The average tumor size for each category was (A) 22.7⫾9.5mm, (B) 51.2⫾22.6mm, (C) 29.9⫾8.7mm, and (D) 36.3⫾11.3mm. The numbers of positive findings for lymphatic involvement,
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venous involvement, nodal metastasis and distant metastasis for each category were: (A) 50(67.6%), 54(73.0%), 18(24.3%), 0(0%), (B) 14(53.8%), 12(46.2%), 8(30.8%), 0(0%), (C) 14(58.3%), 8(33.3%), 6(25.0%), 0(0%), (D) 35(49.3%), 41(57.7%), 16(22.5%), 2(2.8%). Category A showed significantly higher rate of lymphatic and venous involvement (P⬍0.01, P⬍0.05 respectively). As for the other factors, there were no significant differences. Conclusion: Compared to the other forms, depressed-type colorectal muscularis propria carcinoma showed higher rate of lymphatic and venous invasion and its malignant nature has been highlighted.
Tu1445 Colonic Endoscopic Mucosal Resection: Is It Safe in the Octogenarian Population? Victoria Gomez*, Mihir K. Patel, Ernest P. Bouras, Massimo Raimondo, Michael B. Wallace, Timothy a. Woodward, Frank Lukens Gastroenterology, Mayo Clinic, Jacksonville, FL Background: With endoscopic mucosal resection (EMR), large, sessile lesions of the colon can be resected endoscopically rather than surgically. While the majority of patients that undergo EMR are over the age of 50, the octogenarian patient population in particular could significantly benefit from EMR, avoiding a surgery that carries more morbidity and even mortality. However, little is known about EMR outcomes in the very elderly patient population. Aim: To evaluate outcomes and safety of colon EMR in the octogenarian patient population. Methods: We performed a retrospective review of the electronic medical records for all patients greater than or equal to 80 years of age that underwent EMR of the colon for lesions greater than or equal to 2 centimeters (cm), from March 2000 to May 2012 at a single tertiary referral center. Demographic information, specifics of the mucosal lesions and outcomes were evaluated. Results: Between the given dates, 132 EMR procedures were performed on 99 patients greater than or equal to 80 years of age. Fifty-nine patients were male, average age was 84 years (Range: 80-93 years) and 94% were Caucasian (N⫽93). Seven patients were greater than or equal to 90 years of age. EMR procedures were more commonly performed in the right colon (N⫽95, 72%). Average polyp size was 3.3 cm (Range 2-12.5 cm). The most frequently diagnosed pathologies were adenomas (N⫽95, 72%), followed by hyperplastic lesions (N⫽16, 12%), adenocarcinoma (N⫽10, 7.6%) and serrated polyps (N⫽7, 5.3%). Ten procedure-related complications occurred (8%). Five of these consisted of either immediate or delayed post polypectomy bleeding that required hospitalization for observation with/without colonoscopy with hemostasis. Four perforations occurred, 3 of which were managed with endoscopic hemostatic clips placement and observation in the hospital, and 1 that required urgent partial cecectomy. One patient experienced significant chest pain, nausea and vomiting after procedure and required hospitalization for observation. No deaths occurred. Six patients ultimately required a colonic operation, including 1 for a procedure related perforation, 4 for adenocarcinoma of the colon and 1 for a recurrent adenoma that was difficult to treat endoscopically. Conclusion: Colonic EMR in the very elderly patient population offers minimally invasive treatment of neoplastic lesions. While complications do occur, overall, EMR can be performed safely and furthermore avoid the need for surgical intervention in most instances.
Tu1446 Rectal Location Confers Increased Risk of Colorectal Cancer in Specific Subgroups of Advanced Mucosal Neoplasia Bronte a. Holt*1, Stephen J. Williams1, Rajvinder Singh2, Luke F. Hourigan3,4, Simon a. Zanati5,6, Gregor J. Brown5,7, Michael J. Bourke1 1 Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; 2Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, SA, Australia; 3Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia; 4Gastroenterology and Hepatology, Greenslopes Private Hospital, Brisbane, QLD, Australia; 5 Gastroenterology and Hepatology, The Alfred Hospital, Melbourne, VIC, Australia; 6Gastroenterology and Hepatology, Western Hospital, Melbourne, VIC, Australia; 7Gastroenterology and Hepatology, Epworth Hospital, Melbourne, VIC, Australia Background: Large sessile polyps and laterally spreading tumours ⬎20mm are advanced colonic mucosal neoplasms (AMN) with a small but significant risk of invasive cancer. Accurate endoscopic assessment informs the therapeutic strategy. En bloc resection is preferred for those at risk of early colorectal cancer (CRC), especially in distal locations where surgery is associated with increased short and long-term morbidity and mortality. Compared to flat (Paris 0-IIa/b) and granular (G) AMN, non granular (NG) AMN or those with a Paris 0-Is component (including Is⫹IIa, and Is⫹IIb subtypes) have an increased risk of submucosal invasion. Rectal location may confer additional risk but this is currently unknown. Patients And Methods: Data from a large, multicentre prospective cohort of EMR for colonic AMN ⱖ20mm was analysed (June 2008- May 2012,
Volume 77, No. 5S : 2013
GASTROINTESTINAL ENDOSCOPY
AB543
Abstracts
ClinicalTrials.gov NCT01368289). Data collection included patient and polyp characteristics, lesion location and histology. Statistical analyses were performed using SPSS 19 (SPSS Inc., Chicago, IL, USA). Results: EMR was performed in 1109 lesions ⬎20mm (910 colon, 82%; 199 rectum, 18%). 37 patients did not have EMR and were excluded from analysis (22 cancer suspected; 15 technical difficulties). Significant differences exist in key patient and lesion characteristics, and procedural success rates (Table 1). Rectal lesions had a significantly higher risk of CRC than colonic lesions (11.5% v 6.0%, P⫽0.007). The odds of CRC in the rectum was 1.6 times greater than in the colon on multiple logistic regression analysis, however was not an independent predictor of CRC (95% CI 0.9-3.0, P⫽0.138). Independent predictors of CRC were Paris classification and morphology, presence of Kudo pit pattern 5 and lesion size (all P⬍0.05). The most common subgroup (0-IIa/b G lesions) had the same low risk for CRC in the colon and rectum (2.3% v 2.4%, P⫽1.000) (Table 2). A Is component in a G lesion magnified the risk of CRC in the colon, which was further increased in the rectum (5.9% v 9.6%, RR 1.63, P⫽0.196). The same applied to 0-IIa/b lesions with NG morphology in the colon compared to the rectum (7.7% v 22.2%, RR 2.87, P⫽0.171). NG lesions with a Is component in the rectum had the highest relative risk of CRC (7.1% v 30.8%, P⫽0.017, RR 4.31, 95% CI for RR 1.2-15.0). Conclusion: Specific subtypes of rectal AMNs have a greater relative risk of CRC compared to colonic AMNs, particularly NG lesions with a Is component. Endoscopic morphology determines the endoscopic therapeutic approach. Independent of site, granular flat lesions can be removed by multi-piece excision, as the risk of CRC is low. However, lesions with a Is component and NG morphology need to be assessed on a case by case basis to determine the correct strategy and should be considered for en bloc resection, particularly when found in the rectum.
surgery. There have been studies which have reported the short term outcomes of large polyp removal using standard methylene blue/epinephrine/saline injection and lift techniques. There are not many long term follow-up studies of these patients to document that large polypectomy has successfully prevented the development of colon cancer. The goal of our retrospective study was to evaluate the long term outcomes of patients that underwent large polyp removal using standard injection and lift techniques. Methods: We reviewed reports in our institution’s endoscopy database from March 2003 to June 2012. Because we wanted to look at long term outcomes, we specifically identified patients who underwent large polypectomy between June 2004 and December 2006. Sixty eight patients who underwent attempted large (⬎20 mm) polypectomy using a methylene blue, epinephrine, and saline lift technique were identified. Following injection at the base of the polyp, removal was accomplished with snare cautery. APC was used for fulguration of residual polyp. The hospital electronic medical record was reviewed to determine long term outcome and rate of tumor recurrence. Results: Sixty eight patients (mean age 63.1 years) underwent 73 attempted lift polypectomies. Seventy-three polyps were removed: 7 were pedunculated and 66 were sessile. Four polyps were not removed as they did not lift with submucosal injection. Fifty-two polyps (71%) were resected piecemeal, while 17 polyps were resected in toto. Mean polyp size was 29.9 mm with a range from 20 mm to 70 mm. Ten patients underwent surgery due to concerning histology or non-lifting polyp. Complications occurred in 12 (16.7%) patients with no mortality. Long term follow-up colonoscopy data (⬎3 years since initial colonoscopy) was available in 36 of 57 (63.2%) non-surgical patients. The longest interval of follow-up in our patient pool was 7 years. One patient was discovered to have a polypoid mass in a different site five years after initial polypectomy. The mass was biopsied and pathology revealed invasive adenocarcinoma. No patients had endoscopic evidence of adenocarcinoma at previous polypectomy site after long term follow-up. Conclusions: Large polypectomies can be performed reasonably safely with a methylene blue/ epinephrine/saline lift technique. This procedure is a minimally invasive outpatient alternative to the surgical resection of large polyps. Long term followup did not reveal any evidence of cancer at the polypectomy sites. This supports the notion that endoscopic removal of large polyps is safe and effective in the prevention of colorectal cancer.
Tu1448 Predictors of Incomplete Resection and Perforation Associated With Endoscopic Submucosal Dissection for Colorectal Tumors Nana Hayashi*1, Shinji Tanaka1, Soki Nishiyama2, Motomi Terasaki2, Koichi Nakadoi2, Hiroyuki Kanao1, Shiro Oka1, Kazuaki Chayama2 1 Endoscopy, Hiroshima University Hospital, Hiroshima, Japan; 2 Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
Key: 0-Is groups include 0-Is, 0-Is⫹c, 0-Is⫹IIa and 0-Is⫹IIb. G⫽granular, NG⫽non granular Tu1447 A Long Term Retrospective Analysis of Large Polypectomies Using Standard Injection and Lift Techniques Ronald W. Ste. Marie*, Niraj Ajmere, Graham F. Barnard, Kanishka Bhattacharya, John Levey, David R. Cave Gastroenterology, University of Massachusetts Medical Center, Worcester, MA
The AIM of this study is to clarify the predictors for incomplete resection and perforation in colorectal endoscopic submucosal dissection (ESD). Methods: A total of 214 consecutive colorectal tumors (adenoma/early carcinoma) treated by ESD from May 2010 to September were included in the analysis. Predictors were evaluated, focusing on size of lesion, gross type, location (colon or rectum), pathologic diagnosis and depth of invasion, bleeding during treatment, degree of fibrosis, history of biopsy, history of previous local endoscopic treatment, endoscopic operability. Also, predictions of endoscopic poor operability were evaluated, focusing on age, sex, history of abdominal operation, location, lesion on the fold or not, lesion on the flexure or not, perpendicular approach to muscular layer or not. Results: The cases of incomplete resection were 9 lesions (4.2%). Perforation during ESD occurred in 13 lesions (6.1%). Univariate analysis identified severe fibrosis (p⫽0.0019) and poor endoscopic operability (p⫽0.0131) as predictors for incomplete resection, and identified severe fibrosis (p⫽0.383), post endoscopic treatment (EMR/ESD) (p⫽0.0127) and poor endoscopic operability (p⫽0.0131) as predictors for perforation. Multivariate analysis identified severe fibrosis and poor endoscopic operability as independent predictors for incomplete resection and perforation. Further, post abdominal operation (p⫽0.0327), location in colon (p⬍0.0001), lesion on the fold (p⫽0.0490), and lesion on the flexure (p⬍0.0001) were identified as predictors for poor endoscopic operability. Conclusions: Lesions with severe fibrosis and poor endoscopic operability were independent significant predictors for incomplete resections and perforation during colorectal ESD. History of abdominal operation, location of colon, lesion on the fold, and lesion on the flexure were significant predictors of poor endoscopic operability. These results will be helpful information prior to colorectal ESD.
Background The introduction of endoscopic mucosal resection (EMR) has permitted the removal of large polyps which were previously only amenable to
AB544 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org
Endoscopic Mucosal Resection Margin and Depth Assessment Scale (EMR-MDA Scale) Nomenclature e p n B B0 B1 E E0 E1 MDA Scale 0 MDA Scale 1 MDA Scale 2
En Bloc resection Piecemeal resection Number of pieces taken during piecemeal resection Base of the resection No neoplastic tissue at resection base-clean base Neoplastic tissue at the resection base Edge of the resection No neoplastic tissue at resection edge; round mucosal pit pattern observed Neoplastic tissue at resection edge EMR MDA Scale eB0E0 (Enbloc resection without residual tissue) p n (ⱕ3)B0E0 (Piecemeal resection, nⱕ3, without residual tissue) p n (⬎3) or B1 or E1 (Piecemeal resection, n⬎3 or residual tissue at base or edge)
Tu1444 Characteristics of Colorectal Muscularis Propria Carcinoma Derived From Depressed- Type Early Lesions Tomokazu Hisayuki*1, Shin-Ei Kudo1, Shigeharu Hamatani2, Hideyuki Miyachi1, Katsuro Ichimasa1, Hiromasa Oikawa1, Yuichi Mori1, Masashi Misawa1, Toyoki Kudo1, Kenta Kodama1, Yoshiki Wada1, Takemasa Hayashi1, Kunihiko Wakamura1, Eiji Hidaka1, Fuyuhiko Yamamura1, Shogo Ohkoshi1, Fumio Ishida1, Jun-Ichi Tanaka1 1 Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan; 2Department of Pathology, Showa University Northern Yokohama Hospital, Yokohama, Japan Backgrounds: The general recognition is that “adenoma-carcinoma sequence” has been considered as the mainstream theory of the development of colorectal cancer. Recently, an increasing number of depressed-type early colorectal cancers are being reported not only in the East but also in the West. Depressedtype early cancers are considered to emerge directly from normal mucosa without going through adenomas and become invasive even when carcinomas as early as they are around 10mm in diameter. Aims: The aim is to clarify the characteristics of colorectal muscularis propria carcinoma derived from depressed-type early lesions. Method: A total of 16200 neoplasms were resected endoscopically or surgically at our unit from April 2001 to April 2009. Of these 195 muscularis propria carcinomas were included. There were 50 lesions(25.6%) with nodal metastasis and 2 lesions(1.0%) with distant metastasis. The lesions were classified into 4 categories based on the endoscopic view: (A) Depressed type (with the periphery consisted of normal mucosa), (B) Laterally spreading type, (C) Protruded type, and (D) Ulcerative type (with the periphery consisted of neoplastic tissue). Category A lesions are the cases which can be estimated to have developed from depressed-type early cancers. We analyzed those lesions in terms of tumor size, lymphatic involvement, venous involvement, nodal metastasis and distant metastasis. Results: The 195 muscularis propria carcinomas were classified as (A) 74 lesions(38.0%), (B) 26 lesions(13.3%), (C) 24 lesions(12.3%), and (D) 71 lesions(36.4%). The average tumor size for each category was (A) 22.7⫾9.5mm, (B) 51.2⫾22.6mm, (C) 29.9⫾8.7mm, and (D) 36.3⫾11.3mm. The numbers of positive findings for lymphatic involvement,
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venous involvement, nodal metastasis and distant metastasis for each category were: (A) 50(67.6%), 54(73.0%), 18(24.3%), 0(0%), (B) 14(53.8%), 12(46.2%), 8(30.8%), 0(0%), (C) 14(58.3%), 8(33.3%), 6(25.0%), 0(0%), (D) 35(49.3%), 41(57.7%), 16(22.5%), 2(2.8%). Category A showed significantly higher rate of lymphatic and venous involvement (P⬍0.01, P⬍0.05 respectively). As for the other factors, there were no significant differences. Conclusion: Compared to the other forms, depressed-type colorectal muscularis propria carcinoma showed higher rate of lymphatic and venous invasion and its malignant nature has been highlighted.
Tu1445 Colonic Endoscopic Mucosal Resection: Is It Safe in the Octogenarian Population? Victoria Gomez*, Mihir K. Patel, Ernest P. Bouras, Massimo Raimondo, Michael B. Wallace, Timothy a. Woodward, Frank Lukens Gastroenterology, Mayo Clinic, Jacksonville, FL Background: With endoscopic mucosal resection (EMR), large, sessile lesions of the colon can be resected endoscopically rather than surgically. While the majority of patients that undergo EMR are over the age of 50, the octogenarian patient population in particular could significantly benefit from EMR, avoiding a surgery that carries more morbidity and even mortality. However, little is known about EMR outcomes in the very elderly patient population. Aim: To evaluate outcomes and safety of colon EMR in the octogenarian patient population. Methods: We performed a retrospective review of the electronic medical records for all patients greater than or equal to 80 years of age that underwent EMR of the colon for lesions greater than or equal to 2 centimeters (cm), from March 2000 to May 2012 at a single tertiary referral center. Demographic information, specifics of the mucosal lesions and outcomes were evaluated. Results: Between the given dates, 132 EMR procedures were performed on 99 patients greater than or equal to 80 years of age. Fifty-nine patients were male, average age was 84 years (Range: 80-93 years) and 94% were Caucasian (N⫽93). Seven patients were greater than or equal to 90 years of age. EMR procedures were more commonly performed in the right colon (N⫽95, 72%). Average polyp size was 3.3 cm (Range 2-12.5 cm). The most frequently diagnosed pathologies were adenomas (N⫽95, 72%), followed by hyperplastic lesions (N⫽16, 12%), adenocarcinoma (N⫽10, 7.6%) and serrated polyps (N⫽7, 5.3%). Ten procedure-related complications occurred (8%). Five of these consisted of either immediate or delayed post polypectomy bleeding that required hospitalization for observation with/without colonoscopy with hemostasis. Four perforations occurred, 3 of which were managed with endoscopic hemostatic clips placement and observation in the hospital, and 1 that required urgent partial cecectomy. One patient experienced significant chest pain, nausea and vomiting after procedure and required hospitalization for observation. No deaths occurred. Six patients ultimately required a colonic operation, including 1 for a procedure related perforation, 4 for adenocarcinoma of the colon and 1 for a recurrent adenoma that was difficult to treat endoscopically. Conclusion: Colonic EMR in the very elderly patient population offers minimally invasive treatment of neoplastic lesions. While complications do occur, overall, EMR can be performed safely and furthermore avoid the need for surgical intervention in most instances.
Tu1446 Rectal Location Confers Increased Risk of Colorectal Cancer in Specific Subgroups of Advanced Mucosal Neoplasia Bronte a. Holt*1, Stephen J. Williams1, Rajvinder Singh2, Luke F. Hourigan3,4, Simon a. Zanati5,6, Gregor J. Brown5,7, Michael J. Bourke1 1 Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; 2Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, SA, Australia; 3Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia; 4Gastroenterology and Hepatology, Greenslopes Private Hospital, Brisbane, QLD, Australia; 5 Gastroenterology and Hepatology, The Alfred Hospital, Melbourne, VIC, Australia; 6Gastroenterology and Hepatology, Western Hospital, Melbourne, VIC, Australia; 7Gastroenterology and Hepatology, Epworth Hospital, Melbourne, VIC, Australia Background: Large sessile polyps and laterally spreading tumours ⬎20mm are advanced colonic mucosal neoplasms (AMN) with a small but significant risk of invasive cancer. Accurate endoscopic assessment informs the therapeutic strategy. En bloc resection is preferred for those at risk of early colorectal cancer (CRC), especially in distal locations where surgery is associated with increased short and long-term morbidity and mortality. Compared to flat (Paris 0-IIa/b) and granular (G) AMN, non granular (NG) AMN or those with a Paris 0-Is component (including Is⫹IIa, and Is⫹IIb subtypes) have an increased risk of submucosal invasion. Rectal location may confer additional risk but this is currently unknown. Patients And Methods: Data from a large, multicentre prospective cohort of EMR for colonic AMN ⱖ20mm was analysed (June 2008- May 2012,
Volume 77, No. 5S : 2013
GASTROINTESTINAL ENDOSCOPY
AB543
Abstracts
ClinicalTrials.gov NCT01368289). Data collection included patient and polyp characteristics, lesion location and histology. Statistical analyses were performed using SPSS 19 (SPSS Inc., Chicago, IL, USA). Results: EMR was performed in 1109 lesions ⬎20mm (910 colon, 82%; 199 rectum, 18%). 37 patients did not have EMR and were excluded from analysis (22 cancer suspected; 15 technical difficulties). Significant differences exist in key patient and lesion characteristics, and procedural success rates (Table 1). Rectal lesions had a significantly higher risk of CRC than colonic lesions (11.5% v 6.0%, P⫽0.007). The odds of CRC in the rectum was 1.6 times greater than in the colon on multiple logistic regression analysis, however was not an independent predictor of CRC (95% CI 0.9-3.0, P⫽0.138). Independent predictors of CRC were Paris classification and morphology, presence of Kudo pit pattern 5 and lesion size (all P⬍0.05). The most common subgroup (0-IIa/b G lesions) had the same low risk for CRC in the colon and rectum (2.3% v 2.4%, P⫽1.000) (Table 2). A Is component in a G lesion magnified the risk of CRC in the colon, which was further increased in the rectum (5.9% v 9.6%, RR 1.63, P⫽0.196). The same applied to 0-IIa/b lesions with NG morphology in the colon compared to the rectum (7.7% v 22.2%, RR 2.87, P⫽0.171). NG lesions with a Is component in the rectum had the highest relative risk of CRC (7.1% v 30.8%, P⫽0.017, RR 4.31, 95% CI for RR 1.2-15.0). Conclusion: Specific subtypes of rectal AMNs have a greater relative risk of CRC compared to colonic AMNs, particularly NG lesions with a Is component. Endoscopic morphology determines the endoscopic therapeutic approach. Independent of site, granular flat lesions can be removed by multi-piece excision, as the risk of CRC is low. However, lesions with a Is component and NG morphology need to be assessed on a case by case basis to determine the correct strategy and should be considered for en bloc resection, particularly when found in the rectum.
surgery. There have been studies which have reported the short term outcomes of large polyp removal using standard methylene blue/epinephrine/saline injection and lift techniques. There are not many long term follow-up studies of these patients to document that large polypectomy has successfully prevented the development of colon cancer. The goal of our retrospective study was to evaluate the long term outcomes of patients that underwent large polyp removal using standard injection and lift techniques. Methods: We reviewed reports in our institution’s endoscopy database from March 2003 to June 2012. Because we wanted to look at long term outcomes, we specifically identified patients who underwent large polypectomy between June 2004 and December 2006. Sixty eight patients who underwent attempted large (⬎20 mm) polypectomy using a methylene blue, epinephrine, and saline lift technique were identified. Following injection at the base of the polyp, removal was accomplished with snare cautery. APC was used for fulguration of residual polyp. The hospital electronic medical record was reviewed to determine long term outcome and rate of tumor recurrence. Results: Sixty eight patients (mean age 63.1 years) underwent 73 attempted lift polypectomies. Seventy-three polyps were removed: 7 were pedunculated and 66 were sessile. Four polyps were not removed as they did not lift with submucosal injection. Fifty-two polyps (71%) were resected piecemeal, while 17 polyps were resected in toto. Mean polyp size was 29.9 mm with a range from 20 mm to 70 mm. Ten patients underwent surgery due to concerning histology or non-lifting polyp. Complications occurred in 12 (16.7%) patients with no mortality. Long term follow-up colonoscopy data (⬎3 years since initial colonoscopy) was available in 36 of 57 (63.2%) non-surgical patients. The longest interval of follow-up in our patient pool was 7 years. One patient was discovered to have a polypoid mass in a different site five years after initial polypectomy. The mass was biopsied and pathology revealed invasive adenocarcinoma. No patients had endoscopic evidence of adenocarcinoma at previous polypectomy site after long term follow-up. Conclusions: Large polypectomies can be performed reasonably safely with a methylene blue/ epinephrine/saline lift technique. This procedure is a minimally invasive outpatient alternative to the surgical resection of large polyps. Long term followup did not reveal any evidence of cancer at the polypectomy sites. This supports the notion that endoscopic removal of large polyps is safe and effective in the prevention of colorectal cancer.
Tu1448 Predictors of Incomplete Resection and Perforation Associated With Endoscopic Submucosal Dissection for Colorectal Tumors Nana Hayashi*1, Shinji Tanaka1, Soki Nishiyama2, Motomi Terasaki2, Koichi Nakadoi2, Hiroyuki Kanao1, Shiro Oka1, Kazuaki Chayama2 1 Endoscopy, Hiroshima University Hospital, Hiroshima, Japan; 2 Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
Key: 0-Is groups include 0-Is, 0-Is⫹c, 0-Is⫹IIa and 0-Is⫹IIb. G⫽granular, NG⫽non granular Tu1447 A Long Term Retrospective Analysis of Large Polypectomies Using Standard Injection and Lift Techniques Ronald W. Ste. Marie*, Niraj Ajmere, Graham F. Barnard, Kanishka Bhattacharya, John Levey, David R. Cave Gastroenterology, University of Massachusetts Medical Center, Worcester, MA
The AIM of this study is to clarify the predictors for incomplete resection and perforation in colorectal endoscopic submucosal dissection (ESD). Methods: A total of 214 consecutive colorectal tumors (adenoma/early carcinoma) treated by ESD from May 2010 to September were included in the analysis. Predictors were evaluated, focusing on size of lesion, gross type, location (colon or rectum), pathologic diagnosis and depth of invasion, bleeding during treatment, degree of fibrosis, history of biopsy, history of previous local endoscopic treatment, endoscopic operability. Also, predictions of endoscopic poor operability were evaluated, focusing on age, sex, history of abdominal operation, location, lesion on the fold or not, lesion on the flexure or not, perpendicular approach to muscular layer or not. Results: The cases of incomplete resection were 9 lesions (4.2%). Perforation during ESD occurred in 13 lesions (6.1%). Univariate analysis identified severe fibrosis (p⫽0.0019) and poor endoscopic operability (p⫽0.0131) as predictors for incomplete resection, and identified severe fibrosis (p⫽0.383), post endoscopic treatment (EMR/ESD) (p⫽0.0127) and poor endoscopic operability (p⫽0.0131) as predictors for perforation. Multivariate analysis identified severe fibrosis and poor endoscopic operability as independent predictors for incomplete resection and perforation. Further, post abdominal operation (p⫽0.0327), location in colon (p⬍0.0001), lesion on the fold (p⫽0.0490), and lesion on the flexure (p⬍0.0001) were identified as predictors for poor endoscopic operability. Conclusions: Lesions with severe fibrosis and poor endoscopic operability were independent significant predictors for incomplete resections and perforation during colorectal ESD. History of abdominal operation, location of colon, lesion on the fold, and lesion on the flexure were significant predictors of poor endoscopic operability. These results will be helpful information prior to colorectal ESD.
Background The introduction of endoscopic mucosal resection (EMR) has permitted the removal of large polyps which were previously only amenable to
AB544 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org