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Tu1458 A Novel Balloon-Colonoscope Increases Adenoma Detection in the Ascending Colon
Abstracts
Tu1456 Endoscopic Mucosal Resection of Advanced Mucosal Neoplasia Involving the Ileocecal Valve With Ileal Infiltration: Endoscopic Features and Outcome Kavinderjit S. Nanda*, Nicholas J. Tutticci, Nicholas G. Burgess, Rebecca Sonson, Stephen J. Williams, Michael J. Bourke Gastroenterology and Hepatology, Westmead Hospital, Wentworthville,, Sydney, NSW, Australia Introduction: Limited data exists on the technical aspects or clinical outcomes for endoscopic mucosal resection (EMR) of Advanced Mucosal Neoplasia (AMN-sessile polyps and laterally spreading tumours R20mm) involving the ileocecal valve (ICV) with/ without ileal infiltration. Conventionally, these lesions are deemed too challenging for endoscopic therapy and are primarily managed surgically. Aim: To describe the characteristics and outcomes of EMR of lesions involving the ICV referred to a tertiary centre. Methods: Prospective single centre data of EMR for ICV AMN over a 60 month period to November 2013 was analyzed. Patient and lesion characteristics, technical factors and outcome were compared to conventional colonic AMN resection. Variables associated with technical success of EMR were assessed with univariable analysis. Results: EMR was planned on 51 patients with ICV AMN: 57% females; mean age 68 years; mean lesion size 40.9mm. Lesions were predominantly Paris 11a or 11a+Is with granular morphology with Kudo pit pattern III or IVCompared to conventional AMN, lesions were larger, more difficult to access, EMR less often attempted, with lower technical success and en bloc resection (Table 1)ICV EMR was attempted in 44/51 (86%) with 8 (16%) patients requiring a 2 stage procedure at 4-6 weeks. Initial resection was considered technically successful in 42/51 (82%). Complication were pain: 2(4.5%), intraprocedural bleeding: 3(7%), post procedural bleeding: 1(2%); with no perforations or strictures. Main EMR histopathological finding was tubulo adenoma/tubulovillous adenoma (84%), with 3 cases of adenocarcinoma within the resection, and 7 with high grade dysplasia88% and 73% completed surveillance colonoscopy at intervals of 4 months (SC1) and 12 months (SC2) respectively. Residual adenoma was detected in 9/37 (24%) at SC1 and 3(11%) at SC2. All early and late recurrences were diminutive and successfully treated endoscopically. Recurrence at ICV was higher than conventional AMNBased on the intention to treat, 10 patients (19.6%) ultimately underwent surgery due to either technical failure of EMR (7) or unfavourable histological finding (3)Factors associated with failure were difficult endoscopic access to the lesion for complete excision, ileal infiltration and involvement of both proximal and distal ICV lips (Table 2). Size and circumferential extent of ICV involvement was not a risk factor for endoscopic treatment failure Conclusions: EMR of ICV lesions is technically challenging, however amongst cases referred to a tertiary centre, surgery can be avoided in 80%. The procedure is safe and effective. Failure is most likely with ileal extension and involvement of both proximal and distal ICV lips. There is a significant risk of recurrence which although treated easily endoscopically in the majority, necessitates careful follow up.
Univariate analysis of ileocecal valve (ICV) advanced mucosal neoplasia (AMN) and all other conventional colonic AMN Mean Size(mm) SD Mean age (years) SD Previous attempt at EMR Access to lesion Easy Difficult Morphology Granular Non Granular Mixed Paris classification 1s 11a 11a+1s others EMR attempted Successful EMR En bloc resection Submucosal fibrosis Adenoma type Conventional adenoma SSA Invasive cancer Intra-procedural bleeding Post procedural bleeding Perforation Early adenoma recurrence (4-6 months)
ICV AMN n[51
Colonic AMN n[1100
P value
40.98 17.2 68.87 10.7 6 (12%) 21 (41%) 30 (59%) 37 (72.5%) 10 (20%) 3 (6%) 3 (6%) 26 (51%) 15 (29%) 7(14%) 44 (86%) 42 (82%) 3 (6%) 7 (17%) 44 (86%) 3 (6%)
36.97 16.9 67.72 11.2 133 (13%) 660 (65%) 355 (35%) 550 (55%) 326 (32%) 124 (12%) 132 (13%) 54(53%) 229 (23%) 92(8.4%) 982 (97%) 418 (94%) 176 (18%) 227 (23%) 795 (80%) 175 (17%)
0.04 0.64 0.99 0.001 0.007
93 (9.3%) 108 (10%) 58 (6%) 2(0.2%) 81 (13%)
0.18 0.30 0.14 0.35 0.56
3 (6%) 3 (7%) 1 (2%) 0 9 (24%)
0.17 0.003 0.003 0.03 0.09 0.05
Univariate analysis of technical success of ileocecal valve (ICV) EMR and technical failure Technical success n[42 Previous attempt at resection
4 (9.5%)
Technical failure p n[9 value 2 (22%)
0.77
AB440 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
Technical success n[42 Caecum involved Any terminal ileal involvement Extensive terminal ileal involvement Size of ICV lesion !40mm O40mm Access to lesion Easy Difficult Circumferential involvement of ICV !25% !50% !75% Location of lesion on ICV Both proximal & distal lip Either proximal or distal lip
Technical failure p n[9 value
39 (93%) 14 (33%)
8 (89%) 8 (89%)
0.12 0.007
1 (2%)
3 (33%)
0.01
19 (45%) 20 (44%)
3 (33%) 6 (67%)
0.62
26 (65%) 15 (36%)
3 (33%) 6 (67%)
0.04
9 (21%) 23 (55%) 29 (69%) 0 1 (11%) 4 (44%)
0.23
13 (31%) 25 (60%)
8 (89%) 1 (11%)
0.009
Tu1457 Improving Complete Endoscopic Mucosal Resection of Large Sessile Colorectal Neoplasia: a Randomized Trial Comparing Snares and Injectate Timothy a. Woodward*, Julia Crook, Massimo Raimondo, Joy Hardee, Michael B. Wallace Mayo Clinic, Jacksonville, FL Introduction: Endoscopic mucosal resection (EMR) is a method for removing sessile or flat neoplasms confined to the superficial layers of the gastrointestinal tract. Injection of a saline or viscous agent into the submucosa prior to EMR is necessary. However repeated injections with exchange of needle accessories is time consuming. Furthermore, residual lesion rates can be as high as 46%, primarily due to piecemeal resection. The goal of this study was to compare two devices: a combined needle and snare unit (iSnareÒ system - hexagonal snare, US Endoscopy) versus an oval Snaremaster with spiral wire (Snaremaster, Olympus),and secondarily to compare non-viscous vs. viscous injectate. Methods: Patients were randomized to one of the two snare types at the time of colonoscopy; only one polyp meeting study criteria was included per patient. Patients were also secondarily randomized to one of two lifting agents: saline or saline+hydroxypropylmethylcellulose (HPMC). The primary outcome measure for efficacy was the "Sydney Resection Quotient (SRQ)" defined as lesion size in mm divided by the number of pieces to resect. Other outcomes of interest were procedure time, presence of residual neoplasia at 3 month follow-up, and complications. A sample size of 140 patients provided sufficient power to detect a magnitude of effect similar to that in the Australian study that introduced the SRQ measure. Results: Of 140 patients, 68 were randomized to the iSnare, 72 to the Snaremaster. Median age was 67 years (range 32 to 88) and 68 (49%) were male. Polyp size ranged from 16mm to 80mm. Despite randomization there were fewer larger polyps (OZ30mm) in the iSnare arm (39%) than in the Snaremaster arm (54%). Polyps were removed piecemeal in 54% of patients with the iSnare vs. 74% with the Snaremaster. The amount of tissure removed per snare attempt (SRQs) was higher with the iSnare (median 13.8mm vs. 7.1mm, pZ0.019). Significance was reduced (pZ0.11) when adjusting for polyp size though the pattern was still evident across polyp sizes. Time to conduct the EMR was less with the iSnare (median 6 vs. 11 mins, p!0.001). Resection was considered complete after the EMR, but prior to supplemental (e.g. APC) methods in 62% with the iSnare vs. 51% with the Snaremaster. Among those with follow-up results, residual neoplasia was found in 22% (10/46) with the iSnare vs. 21% (10/48) with the Snaremaster. There was no difference in complication rates with snare type and no evidence of any differences in outcomes by lifting agent type. Conclusion: This study provides evidence that the integrated needle-snare (iSnare) may be superior to the snare alone for the removal of large flat polyps. Larger studies are needed to assess whether these findings translate to lower residual neoplasia rates at follow-up.
Tu1458 A Novel Balloon-Colonoscope Increases Adenoma Detection in the Ascending Colon Mark Pochapin*1, Seth a. Gross1, Ralf Kiesslich2, Beni Shpak3, Zamir Halpern4 1 Gastroenterology, NYU Langone Medical Center, New York, NY; 2 Department of Internal Medicine and Gastroenterology, St. Marienkrankenhaus Frankfurt, Frankfurt, Germany; 3Institute of Gastroenterology, Laniado Hospital, Netanya, Israel; 4Institute of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
www.giejournal.org
Abstracts
Introduction: In standard colonoscopy (SC), considerable portion of all adenomas are missed in the right colon, particularly in the ascending colon. While only 16% of the adenomas are detected in the ascending colon, up to 55% of the interval CRC incidents are ascending colon cancers. The particularly high adenoma miss-rate in the ascending colon may be attributed in part to its anatomical structure, having prominent folds. This study explores a novel device and technique for increasing adenoma detection by flattening of colon folds during colonoscopy. It employs a unique balloon-colonoscope (G-EYEÔ Endoscope, Smart Medical Systems, Ra’anana, Israel), comprising a standard colonoscope having a reprocessable, permanently integrated balloon at its distal tip (Fig.1). Balloon pressure is controlled by a unique inflation system providing pre-determined, userselectable, anchoring and intermediate (low) pressure levels. G-EYE endoscope withdrawal with the balloon moderately inflated effects flattening of haustral folds and enhances visualization (Fig.2). This study compared the additional adenoma detection of G-EYEÔ colonoscopy with that of standard colonoscopy. Methods: This was a multicenter, randomized tandem colonoscopy study. Patients referred to colonoscopy for screening, surveillance or diagnostic workup, were randomized into two groups. Group A underwent SC followed by G-EYE colonoscopy; Group B underwent G-EYE followed by SC. All-location and ascending colon adenoma additional detection were calculated. During G-EYE colonoscopy, the endoscope was advanced conventionally with the balloon deflated and once the cecum was reached, the balloon was inflated to intermediate pressure and the G-EYE was withdrawn, thus straightening colon folds and improving colon visualization. Results: 106 subjects completed the study, 54 in Group A and 52 in Group B. Adenomas were allocated to: cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid, and rectum. In group A, 2nd pass G-EYE detected 35% (6/17) of its additional adenomas in the ascending colon. In group B, the G-EYEÔ detected 41% (15/37) of its 1st pass adenomas in the ascending colon (compared with 14% for SC). A total of 78 adenomas were detected in this study. 33% (26/78) of these adenomas were detected in the ascending colon, a 2.5 fold higher proportion of ascending colon adenomas as compared with published literature. 81% (21/26) of the adenomas detected in the ascending colon were detected by the G-EYEÔ colonoscope, and 19% (5/26) by the standard colonoscope. No adverse events occurred. Conclusions: The G-EYEÔ endoscope and withdrawal technique were found to be safe, efficient and easy to use. G-EYEÔ colonoscopy exhibited substantially higher adenoma detection in the ascending colon compared with standard colonoscopy. Additional studies are underway.
Tu1459 Inter-Observer Agreement in the Endoscopic Classification of Colorectal Laterally Spreading Tumors: a Multicenter Study Between Experts and Trainees Yoo Jin Lee1, Eun Soo Kim*1, Kyung Sik Park1, Kwangbum Cho1, Sung Kook Kim2, Seongwoo Jeon2, MIN Kyu Jung2, Byung IK Jang3, Kyeong Ok Kim3, SI Hyung Lee3, Eun Young Kim4, Joong Goo Kwon4, Jin Tae Jung4, Wan Jung Kim6, Hyun Jin Kim7, Hang Eun Seo8, Chang Hun Yang5 1 Internal Medicine, Keimyung University School of Medicine, Daegu, Republic of Korea; 2Internal Medicine, Kyungpook University School of Medicine, Daegu, Republic of Korea; 3Internal Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea; 4Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea; 5Internal Medicine, Dongguk University School of Medicine, Kyungju, Republic of Korea; 6Internal Medicine, Soonchunhyang University School of Medicine, Gumi, Republic of Korea; 7 Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Republic of Korea; 8Internal Medicine, Daegu Fatima Hospital, Daegu, Republic of Korea Background and study aims: Although the risk of cancer varies with the subtype of colorectal "laterally spreading tumors" (LSTs), visual interpretations vary among endoscopists. The aim of this study was to evaluate inter-observer agreement and accuracy in the endoscopic classification of LST subtypes among experts and trainees. Methods: In total, 40 LST images were collected and reviewed independently by 14 gastroenterology experts and 10 trainees. All investigators recorded their findings as one of the following four categories: homogeneous, nodular mixed, flat-elevated, and pseudo-depressed. Agreement was assessed in terms of the kappa (k) statistic and AC1 estimate. Accuracy is reported as percentage agreement with the gold standard, based on the gross morphology of the resected specimens. Results: Of the possible 91 pair-wise k estimates among experts, 41 (45.1%) were greater than 0.75, indicating excellent agreement, while only 2 (4.44%) of the 45 pair-wise k estimates among trainees were greater than 0.75. Agreements for individual LST subtypes in the trainee group were significantly lower than those in the expert group. The k and AC1 estimates showed similar values in individual subtypes of LSTs. The overall accuracy of LST was also significantly higher for the experts than the trainees (85.9% vs. 72.5%, p ! 0.001). Notably, the flat-elevated subtype showed the lowest agreement and accuracy and was frequently misclassified as the pseudo-depressed subtype by both groups. Conclusions: Inter-observer agreement and accuracy for LST subtype classification differ significantly between experts and trainees. Implementation of an adequate training system for beginners is necessary to better identify colorectal LSTs.
Tu1460 Improved Detectability of Colon Polyps by Narrow Band Imaging (NBI) Using a New Video Processer System; a Prospective Study Kiyoshi Ogiso*, Naohisa Yoshida, Ryohei Hirose, Yutaka Inada, Tetsuya Okayama, Kazuhiro Katada, Kazuhiro Kamada, Kazuhiko Uchiyama, Osamu Handa, Takeshi Ishikawa, Tomohisa Takagi, Hideyuki Konishi, Nobuaki Yagi, Yuji Naito, Yoshito Itoh Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan Purpose: The brightness and definition were improved in novel NBI by the new video processor system (EVIS LUCERA ELITE: Olympus Co. Tokyo, Japan). The aim of this study was to investigate whether novel NBI could improve detectability of colorectal polyps compared with White Light (WL). Material and method: We studied 175 colorectal polyps lesions (neoplastic: 150 lesions, non-neoplastic: 25 lesions), of which endoscopic movies were captured using WL and NBI at Kyoto Prefectural University of Medicine from April 2013 to November 2013. The evaluation of detectability in both imaging were prospectively performed using the following original detection scoring system; score 3: easily detectable, score 2: carefully detectable, score 1: hardly detectable. The detection score was determined by three persons who did not know the results of examination, not by endoscopic examiner. All cases were divided into two groups by used endoscopes (CF-HQ290: 97 lesions, and CF-FH260AZI or CF-PCF260AZI: 78 lesions). Additionally, the characteristics of lesions detected easier in NBI than WL (NBIOWL) were analyzed compared to NBIZ/!WL lesions. Results: There were 102 lesions in the right side colon, 39 in the left side colon, and 34 in the rectum (1.7 lesions/ person). The mean tumor size was 9.0mm (2-60), 109 lesions were protruding and 66 lesions were superficial type. The mean detection score by NBI was significantly higher than those by WL (2.30.6 vs 2.00.8, P!0.05). The ratios about the status of detection of polyps such as NBIOWL, NBIZWL, and NBI!WL were 37.1% (65 lesions), 56.6% (99 lesions), and 6.3% (11 lesions), respectively. With respect to kinds of scopes, the mean detection score by NBI was also significantly higher than WL (2.40.7 vs 1.90.7, P!0.05) in CF-HQ290 group. But it was not significant in CF-FH260AZI or
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Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB441
Tu1456 Endoscopic Mucosal Resection of Advanced Mucosal Neoplasia Involving the Ileocecal Valve With Ileal Infiltration: Endoscopic Features and Outcome Kavinderjit S. Nanda*, Nicholas J. Tutticci, Nicholas G. Burgess, Rebecca Sonson, Stephen J. Williams, Michael J. Bourke Gastroenterology and Hepatology, Westmead Hospital, Wentworthville,, Sydney, NSW, Australia Introduction: Limited data exists on the technical aspects or clinical outcomes for endoscopic mucosal resection (EMR) of Advanced Mucosal Neoplasia (AMN-sessile polyps and laterally spreading tumours R20mm) involving the ileocecal valve (ICV) with/ without ileal infiltration. Conventionally, these lesions are deemed too challenging for endoscopic therapy and are primarily managed surgically. Aim: To describe the characteristics and outcomes of EMR of lesions involving the ICV referred to a tertiary centre. Methods: Prospective single centre data of EMR for ICV AMN over a 60 month period to November 2013 was analyzed. Patient and lesion characteristics, technical factors and outcome were compared to conventional colonic AMN resection. Variables associated with technical success of EMR were assessed with univariable analysis. Results: EMR was planned on 51 patients with ICV AMN: 57% females; mean age 68 years; mean lesion size 40.9mm. Lesions were predominantly Paris 11a or 11a+Is with granular morphology with Kudo pit pattern III or IVCompared to conventional AMN, lesions were larger, more difficult to access, EMR less often attempted, with lower technical success and en bloc resection (Table 1)ICV EMR was attempted in 44/51 (86%) with 8 (16%) patients requiring a 2 stage procedure at 4-6 weeks. Initial resection was considered technically successful in 42/51 (82%). Complication were pain: 2(4.5%), intraprocedural bleeding: 3(7%), post procedural bleeding: 1(2%); with no perforations or strictures. Main EMR histopathological finding was tubulo adenoma/tubulovillous adenoma (84%), with 3 cases of adenocarcinoma within the resection, and 7 with high grade dysplasia88% and 73% completed surveillance colonoscopy at intervals of 4 months (SC1) and 12 months (SC2) respectively. Residual adenoma was detected in 9/37 (24%) at SC1 and 3(11%) at SC2. All early and late recurrences were diminutive and successfully treated endoscopically. Recurrence at ICV was higher than conventional AMNBased on the intention to treat, 10 patients (19.6%) ultimately underwent surgery due to either technical failure of EMR (7) or unfavourable histological finding (3)Factors associated with failure were difficult endoscopic access to the lesion for complete excision, ileal infiltration and involvement of both proximal and distal ICV lips (Table 2). Size and circumferential extent of ICV involvement was not a risk factor for endoscopic treatment failure Conclusions: EMR of ICV lesions is technically challenging, however amongst cases referred to a tertiary centre, surgery can be avoided in 80%. The procedure is safe and effective. Failure is most likely with ileal extension and involvement of both proximal and distal ICV lips. There is a significant risk of recurrence which although treated easily endoscopically in the majority, necessitates careful follow up.
Univariate analysis of ileocecal valve (ICV) advanced mucosal neoplasia (AMN) and all other conventional colonic AMN Mean Size(mm) SD Mean age (years) SD Previous attempt at EMR Access to lesion Easy Difficult Morphology Granular Non Granular Mixed Paris classification 1s 11a 11a+1s others EMR attempted Successful EMR En bloc resection Submucosal fibrosis Adenoma type Conventional adenoma SSA Invasive cancer Intra-procedural bleeding Post procedural bleeding Perforation Early adenoma recurrence (4-6 months)
ICV AMN n[51
Colonic AMN n[1100
P value
40.98 17.2 68.87 10.7 6 (12%) 21 (41%) 30 (59%) 37 (72.5%) 10 (20%) 3 (6%) 3 (6%) 26 (51%) 15 (29%) 7(14%) 44 (86%) 42 (82%) 3 (6%) 7 (17%) 44 (86%) 3 (6%)
36.97 16.9 67.72 11.2 133 (13%) 660 (65%) 355 (35%) 550 (55%) 326 (32%) 124 (12%) 132 (13%) 54(53%) 229 (23%) 92(8.4%) 982 (97%) 418 (94%) 176 (18%) 227 (23%) 795 (80%) 175 (17%)
0.04 0.64 0.99 0.001 0.007
93 (9.3%) 108 (10%) 58 (6%) 2(0.2%) 81 (13%)
0.18 0.30 0.14 0.35 0.56
3 (6%) 3 (7%) 1 (2%) 0 9 (24%)
0.17 0.003 0.003 0.03 0.09 0.05
Univariate analysis of technical success of ileocecal valve (ICV) EMR and technical failure Technical success n[42 Previous attempt at resection
4 (9.5%)
Technical failure p n[9 value 2 (22%)
0.77
AB440 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
Technical success n[42 Caecum involved Any terminal ileal involvement Extensive terminal ileal involvement Size of ICV lesion !40mm O40mm Access to lesion Easy Difficult Circumferential involvement of ICV !25% !50% !75% Location of lesion on ICV Both proximal & distal lip Either proximal or distal lip
Technical failure p n[9 value
39 (93%) 14 (33%)
8 (89%) 8 (89%)
0.12 0.007
1 (2%)
3 (33%)
0.01
19 (45%) 20 (44%)
3 (33%) 6 (67%)
0.62
26 (65%) 15 (36%)
3 (33%) 6 (67%)
0.04
9 (21%) 23 (55%) 29 (69%) 0 1 (11%) 4 (44%)
0.23
13 (31%) 25 (60%)
8 (89%) 1 (11%)
0.009
Tu1457 Improving Complete Endoscopic Mucosal Resection of Large Sessile Colorectal Neoplasia: a Randomized Trial Comparing Snares and Injectate Timothy a. Woodward*, Julia Crook, Massimo Raimondo, Joy Hardee, Michael B. Wallace Mayo Clinic, Jacksonville, FL Introduction: Endoscopic mucosal resection (EMR) is a method for removing sessile or flat neoplasms confined to the superficial layers of the gastrointestinal tract. Injection of a saline or viscous agent into the submucosa prior to EMR is necessary. However repeated injections with exchange of needle accessories is time consuming. Furthermore, residual lesion rates can be as high as 46%, primarily due to piecemeal resection. The goal of this study was to compare two devices: a combined needle and snare unit (iSnareÒ system - hexagonal snare, US Endoscopy) versus an oval Snaremaster with spiral wire (Snaremaster, Olympus),and secondarily to compare non-viscous vs. viscous injectate. Methods: Patients were randomized to one of the two snare types at the time of colonoscopy; only one polyp meeting study criteria was included per patient. Patients were also secondarily randomized to one of two lifting agents: saline or saline+hydroxypropylmethylcellulose (HPMC). The primary outcome measure for efficacy was the "Sydney Resection Quotient (SRQ)" defined as lesion size in mm divided by the number of pieces to resect. Other outcomes of interest were procedure time, presence of residual neoplasia at 3 month follow-up, and complications. A sample size of 140 patients provided sufficient power to detect a magnitude of effect similar to that in the Australian study that introduced the SRQ measure. Results: Of 140 patients, 68 were randomized to the iSnare, 72 to the Snaremaster. Median age was 67 years (range 32 to 88) and 68 (49%) were male. Polyp size ranged from 16mm to 80mm. Despite randomization there were fewer larger polyps (OZ30mm) in the iSnare arm (39%) than in the Snaremaster arm (54%). Polyps were removed piecemeal in 54% of patients with the iSnare vs. 74% with the Snaremaster. The amount of tissure removed per snare attempt (SRQs) was higher with the iSnare (median 13.8mm vs. 7.1mm, pZ0.019). Significance was reduced (pZ0.11) when adjusting for polyp size though the pattern was still evident across polyp sizes. Time to conduct the EMR was less with the iSnare (median 6 vs. 11 mins, p!0.001). Resection was considered complete after the EMR, but prior to supplemental (e.g. APC) methods in 62% with the iSnare vs. 51% with the Snaremaster. Among those with follow-up results, residual neoplasia was found in 22% (10/46) with the iSnare vs. 21% (10/48) with the Snaremaster. There was no difference in complication rates with snare type and no evidence of any differences in outcomes by lifting agent type. Conclusion: This study provides evidence that the integrated needle-snare (iSnare) may be superior to the snare alone for the removal of large flat polyps. Larger studies are needed to assess whether these findings translate to lower residual neoplasia rates at follow-up.
Tu1458 A Novel Balloon-Colonoscope Increases Adenoma Detection in the Ascending Colon Mark Pochapin*1, Seth a. Gross1, Ralf Kiesslich2, Beni Shpak3, Zamir Halpern4 1 Gastroenterology, NYU Langone Medical Center, New York, NY; 2 Department of Internal Medicine and Gastroenterology, St. Marienkrankenhaus Frankfurt, Frankfurt, Germany; 3Institute of Gastroenterology, Laniado Hospital, Netanya, Israel; 4Institute of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
www.giejournal.org
Abstracts
Introduction: In standard colonoscopy (SC), considerable portion of all adenomas are missed in the right colon, particularly in the ascending colon. While only 16% of the adenomas are detected in the ascending colon, up to 55% of the interval CRC incidents are ascending colon cancers. The particularly high adenoma miss-rate in the ascending colon may be attributed in part to its anatomical structure, having prominent folds. This study explores a novel device and technique for increasing adenoma detection by flattening of colon folds during colonoscopy. It employs a unique balloon-colonoscope (G-EYEÔ Endoscope, Smart Medical Systems, Ra’anana, Israel), comprising a standard colonoscope having a reprocessable, permanently integrated balloon at its distal tip (Fig.1). Balloon pressure is controlled by a unique inflation system providing pre-determined, userselectable, anchoring and intermediate (low) pressure levels. G-EYE endoscope withdrawal with the balloon moderately inflated effects flattening of haustral folds and enhances visualization (Fig.2). This study compared the additional adenoma detection of G-EYEÔ colonoscopy with that of standard colonoscopy. Methods: This was a multicenter, randomized tandem colonoscopy study. Patients referred to colonoscopy for screening, surveillance or diagnostic workup, were randomized into two groups. Group A underwent SC followed by G-EYE colonoscopy; Group B underwent G-EYE followed by SC. All-location and ascending colon adenoma additional detection were calculated. During G-EYE colonoscopy, the endoscope was advanced conventionally with the balloon deflated and once the cecum was reached, the balloon was inflated to intermediate pressure and the G-EYE was withdrawn, thus straightening colon folds and improving colon visualization. Results: 106 subjects completed the study, 54 in Group A and 52 in Group B. Adenomas were allocated to: cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid, and rectum. In group A, 2nd pass G-EYE detected 35% (6/17) of its additional adenomas in the ascending colon. In group B, the G-EYEÔ detected 41% (15/37) of its 1st pass adenomas in the ascending colon (compared with 14% for SC). A total of 78 adenomas were detected in this study. 33% (26/78) of these adenomas were detected in the ascending colon, a 2.5 fold higher proportion of ascending colon adenomas as compared with published literature. 81% (21/26) of the adenomas detected in the ascending colon were detected by the G-EYEÔ colonoscope, and 19% (5/26) by the standard colonoscope. No adverse events occurred. Conclusions: The G-EYEÔ endoscope and withdrawal technique were found to be safe, efficient and easy to use. G-EYEÔ colonoscopy exhibited substantially higher adenoma detection in the ascending colon compared with standard colonoscopy. Additional studies are underway.
Tu1459 Inter-Observer Agreement in the Endoscopic Classification of Colorectal Laterally Spreading Tumors: a Multicenter Study Between Experts and Trainees Yoo Jin Lee1, Eun Soo Kim*1, Kyung Sik Park1, Kwangbum Cho1, Sung Kook Kim2, Seongwoo Jeon2, MIN Kyu Jung2, Byung IK Jang3, Kyeong Ok Kim3, SI Hyung Lee3, Eun Young Kim4, Joong Goo Kwon4, Jin Tae Jung4, Wan Jung Kim6, Hyun Jin Kim7, Hang Eun Seo8, Chang Hun Yang5 1 Internal Medicine, Keimyung University School of Medicine, Daegu, Republic of Korea; 2Internal Medicine, Kyungpook University School of Medicine, Daegu, Republic of Korea; 3Internal Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea; 4Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea; 5Internal Medicine, Dongguk University School of Medicine, Kyungju, Republic of Korea; 6Internal Medicine, Soonchunhyang University School of Medicine, Gumi, Republic of Korea; 7 Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Republic of Korea; 8Internal Medicine, Daegu Fatima Hospital, Daegu, Republic of Korea Background and study aims: Although the risk of cancer varies with the subtype of colorectal "laterally spreading tumors" (LSTs), visual interpretations vary among endoscopists. The aim of this study was to evaluate inter-observer agreement and accuracy in the endoscopic classification of LST subtypes among experts and trainees. Methods: In total, 40 LST images were collected and reviewed independently by 14 gastroenterology experts and 10 trainees. All investigators recorded their findings as one of the following four categories: homogeneous, nodular mixed, flat-elevated, and pseudo-depressed. Agreement was assessed in terms of the kappa (k) statistic and AC1 estimate. Accuracy is reported as percentage agreement with the gold standard, based on the gross morphology of the resected specimens. Results: Of the possible 91 pair-wise k estimates among experts, 41 (45.1%) were greater than 0.75, indicating excellent agreement, while only 2 (4.44%) of the 45 pair-wise k estimates among trainees were greater than 0.75. Agreements for individual LST subtypes in the trainee group were significantly lower than those in the expert group. The k and AC1 estimates showed similar values in individual subtypes of LSTs. The overall accuracy of LST was also significantly higher for the experts than the trainees (85.9% vs. 72.5%, p ! 0.001). Notably, the flat-elevated subtype showed the lowest agreement and accuracy and was frequently misclassified as the pseudo-depressed subtype by both groups. Conclusions: Inter-observer agreement and accuracy for LST subtype classification differ significantly between experts and trainees. Implementation of an adequate training system for beginners is necessary to better identify colorectal LSTs.
Tu1460 Improved Detectability of Colon Polyps by Narrow Band Imaging (NBI) Using a New Video Processer System; a Prospective Study Kiyoshi Ogiso*, Naohisa Yoshida, Ryohei Hirose, Yutaka Inada, Tetsuya Okayama, Kazuhiro Katada, Kazuhiro Kamada, Kazuhiko Uchiyama, Osamu Handa, Takeshi Ishikawa, Tomohisa Takagi, Hideyuki Konishi, Nobuaki Yagi, Yuji Naito, Yoshito Itoh Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan Purpose: The brightness and definition were improved in novel NBI by the new video processor system (EVIS LUCERA ELITE: Olympus Co. Tokyo, Japan). The aim of this study was to investigate whether novel NBI could improve detectability of colorectal polyps compared with White Light (WL). Material and method: We studied 175 colorectal polyps lesions (neoplastic: 150 lesions, non-neoplastic: 25 lesions), of which endoscopic movies were captured using WL and NBI at Kyoto Prefectural University of Medicine from April 2013 to November 2013. The evaluation of detectability in both imaging were prospectively performed using the following original detection scoring system; score 3: easily detectable, score 2: carefully detectable, score 1: hardly detectable. The detection score was determined by three persons who did not know the results of examination, not by endoscopic examiner. All cases were divided into two groups by used endoscopes (CF-HQ290: 97 lesions, and CF-FH260AZI or CF-PCF260AZI: 78 lesions). Additionally, the characteristics of lesions detected easier in NBI than WL (NBIOWL) were analyzed compared to NBIZ/!WL lesions. Results: There were 102 lesions in the right side colon, 39 in the left side colon, and 34 in the rectum (1.7 lesions/ person). The mean tumor size was 9.0mm (2-60), 109 lesions were protruding and 66 lesions were superficial type. The mean detection score by NBI was significantly higher than those by WL (2.30.6 vs 2.00.8, P!0.05). The ratios about the status of detection of polyps such as NBIOWL, NBIZWL, and NBI!WL were 37.1% (65 lesions), 56.6% (99 lesions), and 6.3% (11 lesions), respectively. With respect to kinds of scopes, the mean detection score by NBI was also significantly higher than WL (2.40.7 vs 1.90.7, P!0.05) in CF-HQ290 group. But it was not significant in CF-FH260AZI or
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Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB441