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W1447: Endoscopic Mucosal Resection and Modified Endoscopic Submucosal Dissection for Removal of Large Sessile Colonic Polyps: 1-Year Single Operator Experience in the USA
Abstracts efficacy of repeat polypectomy for recurrent polyps.Methods: We identified all patients who underwent polypectomy for polyps ⱖ 2cm at our institution from 1999-2008. Patient medical records were reviewed to determine recurrence rate and complications. Patients with known polyps referred to advanced endoscopists for EMR were excluded.Results: During study period 348 patients underwent polypectomy and complete follow-up. The average age of study subjects was 61 years and 56% were women. The average size of polyp removed was 31 mm and 69% of polyps were sessile. High-grade dysplasia was noted in 17% of polyps, and invasive cancer in 4.3% of polyps. On follow-up, a recurrent adenomatous polyp was noted at the polypectomy site in 99 patients (28%). Bleeding occurred during procedure in 37 patients and was successfully treated endoscopically in all cases. Bleeding was delayed in 6 patients and 1 patient developed colonic stenosis. Of the 99 patients with residual adenomatous tissue at polypectomy site, 5 were referred for surgery. The remaining 94 patients underwent a repeat polypectomy. Residual adenomatous tissue at the polypectomy site was noted in 22 patients at third colonoscopy. Overall polyp recurrence rate at the end of third colonoscopy was 22 / 348 [6.3%]. Age [OR⫽1.02] and piecemeal resection [OR⫽1.89] were associated with risk of polyp recurrence. Polyp size, sessile nature and appearance of complete resection at the time of polypectomy were not.In our study, polypectomy was performed by 34 endoscopists. A large variation in polyp recurrence was noted amongst endoscopist [range 19% - 75%]. No association was found between total number of colonoscopies performed / year [p ⫽ 0.9] or total number of polypectomies of polyps ⱖ 2 cm performed / year [p ⫽ 0.6] and polyp recurrence.Conclusion: Polypectomy of large polyps and recurrent polyps can be safely performed in routine clinical practice, however recurrence rates remain high. Advanced polyp resection techniques like EMR may substantially reduce recurrence rates and should be considered at initial treatment for large polyps.
W1444 Vascular Patterns Assessed by Vascular Analysis Software Are Predictive of Relapse in Patients With Inactive Ulcerative Colitis Toshiya Okahisa, Miho Tsuda, Tetsu Tomonari, Atsushi Inoue, Tetsuo Kimura, Shinji Kitamura, Hiromi Yano, Hisashi Takeuchi, Koichi Okamoto, Miyako Niki, Masako Kaji, Seisuke Okamura, Ryota Kanno, Shinsuke Konaka, Emoto Takahiro, Masatake Akutagawa, Tetsuji Takayama [Background] Mucosal healing has been incorporated in the assessment of treatment efficacy in the patient with ulcerative colitis (UC). However, there are some cases of endoscopically inactive mucosa which is inconsistent with histological activity and early recurrence in UC. In this study, we evaluated the usefulness of vascular pattern analysis using the vascular analysis software in order to evaluate the histological activity and predict the relapse in patients with inactive UC. [Methods] The mucosal vascular patterns in 214 colorectal segments of 28 patients with inactive UC were observed using conventional colonoscope (CF-H260AZI, Olympus, Tokyo, Japan). Vascular density (VD), number of intersection or diverging points (NID), and fractal dimension (FD) of the thick capillaries or veins in each segment were calculated using the vascular analysis software. Histological inflammation grades were also assessed in mucosal biopsy specimens. The patients were followed until relapse or for a maximum of 12 months. [Results] Positive correlations were identified among VD, NID, FD, and histological grade. Relapse rate was 21.4%. Multivaridate proportional hazard model analysis showed that VD, NID, and FD were significant predictor of relapse (relative risk: VD 1.63; NID 2.45; FD1.94). [Conclusion] Vascular pattern parameters assessed by vascular analysis software are associated with the degree of inflammation, and may predict the probability of subsequent relapse in patient with inactive ulcerative colitis.
W1445 Regional Differences in Colon Circumference and Wall Thickness Erick Salvatierra; Todd Spataro; Jaiyeola Thomas; Ankur Sheth; James Traylor; Long Jin; Anil Minoch; Jerry McLarty Introduction: It has been conventional teaching that electrosurgical intervention and mucosal polypectomy in the cecum and right colon are associated with higher risk of complications like perforation and post polypectomy syndrome secondary to relatively thin walled right colon compared to left colon. However, the published literature noting regional differences in the colon wall is sparse. In addition there is no data regarding gender differences in colon thickness.The aim of our study was to measure and document the differences in bowel wall thickness, layers and circumference in different parts of the colon. Materials and Methods: Twenty-five colon samples were studied from forensic and medical autopsy cases of deceased adults without significant bowel disease or abdominal trauma. Eleven sections were obtained from each colon and 3 mm sections were stained with Hematoxylin and Eosin stain. Layers of colonic wall in each section were measured using a micrometer with appropriate conversion factors on an Olympus microscope. Results: Colon samples from 19 males and 6 females with
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Volume 71, No. 5 : 2010
mean age of 38.48 years were evaluated. The mean circumference decreased progressively from proximal to distal colon (cecum 13.2 cm, rectum 6.6 cm; p⬍0.001). The mean colon wall thickness progressively increased from cecum to sigmoid colon (cecum: 1.17 mm, ascending colon: 1.42 mm, transverse colon: 1.48 mm, descending colon: 1.55 mm, sigmoid colon: 2.27 mm; P ⬍0.006 for cecum compared to sigmoid colon). There was statistically significant increase in thickness of mucosal layer (cecum 0.227 mm, rectum 0.363 mm, p⬍0.02) and muscularis propria (cecum 0.366 mm, rectum 1.09 mm; p⬍0.02) from cecum to rectum. Subset gender analysis showed that males had larger circumference of proximal colon (ascending colon 12.1 cm vs 7.7 cm; p⬍0.03) and females have thicker distal colon wall (sigmoid colon 1.53 mm vs 3.69 mm; p⬍0.001). Females were also noted to have thicker muscularis propria through out the colon (ascending colon: 0.64 vs 0.35 mm; p ⬍0.001, sigmoid colon: 1.44 mm vs 0.75 mm; p⬍0.022, rectum: 1.31 mm vs 0.88 mm; p⬍0.04). Conclusion: Our study shows that the cecum has the largest circumference in the colon. This may account for increased risk of perforation with barotrauma, pseudoileus and post obstructive distention based on Laplace’s law. The cecal wall is significantly thinner in full thickness as well in mucosal and muscularis propria layers. This may account for high risk of post polypectomy perforation and transmural burn injury.
W1446 Colorectal ESD; Treatment Results and Management of Complications Takemasa Hayashi, Hiroshi Kashida, Toshihisa Hosoya, Yoshiki Wada, Hideyuki Miyachi, Nobunao Ikehara, Fuyuhiko Yamamura, Kazuo Ohtsuka, Shin-Ei Kudo [Background]Endoscopic submucosal dissection (ESD) enables en-bloc resection of large neoplastic lesions in the gastrointestinal tract. En-bloc resection is particularly desirable in lesions suspicious of being invasive, because it allows precise histopathological evaluation which is important for preventing a recurrence and/or metastasis. Although ESD technique is almost established for the treatment of upper gastrointestinal (GI) neoplasia, it is not yet accepted as a standard treatment for colorectal lesions because of technical difficulty and complications. Thanks to recent the modification of dissecting knives and hemostatic forceps, advent of thicker solution for submucosal injection (ex. hyaluronic acid) and more sophisticated high-frequency generator, etc, ESD procedures are becoming safer and easier. The aim of this study is to clarify efficacy of ESD for the treatment of colorectal neoplasia.[Methods]We have treated 158 colorectal adenomas and early cancers with ESD technique since September 2003. Among them 90 lesions were treated during the recent one year, and these were evaluated in this study. The procedures were performed with endoscopes with water jet system (GIF-Q260J and PCF-Q260JI; Olympus) with CO2 insufflation instead of room air insufflation to reduce patient‘s discomfort. Glycerol and hyaluronate solution were used for injection to the submucosal layer. Erbotom ICC 200 (Erbe Elektromedizin Ltd) was used as a high⫺frequency generator. Knives used were Flush Knife (Fujinon;Tokyo) and Dual Knife(Olympus;Tokyo). Coagrasper (Olympus;Tokyo) was used for hemostasis. [Results] We assessed the rate of en bloc resection, complete resection and curative resection, adverse events and complications. The respective rates of en⫺bloc resection, complete resection (the horizontal and vertical margins are free of tumor) and curative resection were 95.6%, 93.3%, and 77.8%. Because of thin colorectal wall and limited maneuverability of the endoscope in the colorectum, proper muscle layer can receive damage easily. The moderate damage of the muscle layer occured during the procedure in 15 cases. These patients were observed carefully with conservative medical treatment after immediate closure of the tear with endo clips. There was no need for surgical intervention although, air leakage (perforation) was recognized with x-ray in one of them. No delayed perforation occurred. There was no bleeding after ESD [Conclusion] Advancement of devices has enabled easier and safer ESD procedure. Even if the muscle layer is damaged, immediate closure of the wound prevents significant perforation and emergent surgery.
W1447 Endoscopic Mucosal Resection and Modified Endoscopic Submucosal Dissection for Removal of Large Sessile Colonic Polyps: 1-Year Single Operator Experience in the USA Sergey V. Kantsevoy, Andrew Zhigalin Background: Development of endoscopic submucosal dissection (ESD) in Japan enabled endoscopic removal of large sessile and flat colonic polyps. However, ESD technique is difficult and requires accessories which are not readily available in the USA. Aim: To compare efficacy and safety of endoscopic mucosal resection (EMR) and modified ESD for removal of large flat colonic polyps. Methods: We performed retrospective chart review of all polypectomies performed at Mercy Medical Center from October 2008 till October 2009. Only patients with sessile and flat colonic polyps larger than 2 cm in diameter were included into this study. EMR was performed utilizing submucosal normal saline
www.giejournal.org
Abstracts injection and traditional lift-end-cut technique with a polypectomy snare. Modified ESD also required submucosal injections of normal saline followed by circumferential incision around the polyp made with the tip of a polypectomy snare. Then the snare was placed into the incision surrounding the polyp, tightened, and electrical current was applied to cut off the polyp. A follow-up colonoscopy in 3-6 months was recommended to all patients to rule out any residual polypoid tissue at the polypectomy site. Results: Large sessile and flat colonic polyps were endoscopically removed in 67 patients. In 34 patients the polyps were removed by EMR and in 33 patients the polyps were removed by modified ESD. Both groups were similar by the mean age of the patients (62.0⫾12.6 and 65.0⫾11.6), the size of the polyps (2.9⫾1.0 cm versus 2.9⫾0.9 cm), and the presence of malignancy (5 patients with high grade dysplasia [14.7% and 15.2%] and 2 patients with adenocarcinoma [5.9% and 6.1%] in each group). EMR required significantly less fluid for submucosal injection comparing with modified ESD (26.8⫾14.3 cc vs 40.0⫾16.3 cc, P⫽0.0008), Delayed bleeding occurred in 2 patients (5.9%) post EMR but only in 1 patient (3.0%) post modified ESD. There was 1 perforation post EMR (2.9%) and no perforations post modified ESD. Repeat colonoscopy was performed in 13 patients (38.2%) post EMR and in 15 patients (45.5%) post modified ESD. In 3 patients post EMR residual polypoid tissue was found and successfully removed from the previous polypectomy sites. There was no residual polypoid tissue found in any patients who had modified ESD. Conclusion: For endoscopic removal of large sessile colonic polyps modified ESD appears safer and provides better results comparing with traditional EMR.
W1448 Risk Factors and Prediction of Ischemic Colitis vs. Diverticulosis As the Cause of Severe Hematochezia Using Multivariate Analysis and Classification Tree Modeling Disaya Chavalitdhamrong, Dennis M. Jensen, Daniella Markovic, Jeffrey Gornbein, Mary Ellen Jensen, Nan Sun Both diverticulosis (TICS) & ischemic colitis (IC) are common causes of severe hematochezia (LGIB). Accurately predicting the diagnosis of IC vs. TICS early from clinical parameters could improve treatments & outcomes. PURPOSE: To assess clinical risk factors for predicting IC vs TICS and develop a predictive algorithm. METHODS:. A CURE DDRC data base of 208 consecutive patients in the last 12 years with LGIB from colonic causes was used and analyzed using both backward logistic regression (LR) & classification tree (CT) models. All patients had urgent colonoscopy after PEG-based oral purges. RESULTS: Table 1 shows additive logistic model risk factors of IC. For the CT, 5 variables were used: outpatient start of bleed vs. inpatient start, age, black, prognosis score (prog #), & PTT (sec). (Renal severity was borderline). In CT, odds of IC vs. TICS was highest in inpatient bleed (OR⫽4.91, p⫽0.000). Next highest risk were nonblack outpatients ⬍75 yrs old, prog #⬍3.5 & PTT⬎24.7scc (OR⫽2.81, p⫽0.0017). Those non-black outpatients with prog #⬍3.5, and PTT⬍24 were more likely to be TICS (OR for IC⫽0.40, p⫽0.23) as were non-black outpatients ⬍ 75 yrs old with prog # ⬎ 3.5 (OR⫽0.0 , p⫽0.079). Black outpatients ⬍ 75 years were also more likely to have TICS (OR⫽0.287, p⫽0.041) as was any outpatient over age 75 (OR⫽0.248, p ⫽ 0.0006). Overall accuracy of LR vs. CT was 77% vs. 79%; sensitivity for ischemia was 70.8% vs. 80%.; specificity for TICS was 83% vs. 78%; & concordance (ROC area) was 0.84 vs. 0.81. CONCLUSIONS: 1) Clinical parameters can predict whether IC or TICS is the cause of LGIB. 2) Independent predictors of IC are inpatient start of bleeding, non-black race & female gender; predictors of TIC hemorrhage are older age, black race, & higher prognosis score. 3) Classification tree & logistic models were similar in accuracy, sensitivity & concordance. These results may be useful clinically to predict IC or TICS as the cause of severe LGIB. Supported in part by NIH Grants (K24-DK002650) & CURE Human Studies Core (P30DK041301). Table 1: Logistic Regression for IC vs. TICS Inpatient vs. Outpatient Start of Bleed Other Race vs. Black Renal Disease Female vs. Male Age (per year) Heart Disease (Moderate/ Severe vs. Mild/None) Prognostic Score (per unit)
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Odds Ratio
Lower CI
Upper CI
P-Value
8.26
3.01
22.73
⬍0.0001
4.08 3.42 2.65 0.94 2.49
1.45 1.21 1.24 0.91 0.97
11.49 9.67 5.66 0.98 6.39
0.008 0.020 0.012 0.0005 0.059
0.71
0.49
1.04
0.075
W1449 Epidemiology of the Phenotypes of Inflammatory Bowel Disease Among an Indigent Multi-Ethnic Patient Population in the United States Hoda M. Malaty, Jason Hou, Selvi Thirumurthi Background: There is a paucity of data on the epidemiologic features and clinical manifestations of inflammatory bowel disease (IBD) among patients of low socioeconomic status in the United States. Aim: To examine and compare the epidemiologic features of IBD among African American, Hispanic and Caucasian patients from a County Hospital where the majority of the patients are socioeconomically disadvantaged. Methods: A retrospective investigation was conducted on a cohort of adult patients diagnosed with IBD based on clinical, radiologic, endoscopic and histologic data. The study reviewed charts of adults aged 20 to 70 suspected of having IBD between 2000 and 2006. Demographic data, disease sub-type and phenotypic features of IBD were recorded. The data were analyzed using the Chi-square, Fisher exact and Student t-tests. Results: The study cohort included 279 patients with 54% female, 30% Caucasian, 44% African American and 26% Hispanic. Over half of the patients had Crohn’s disease (CD, 54%) and 46% had ulcerative colitis (UC). The mean age at diagnosis was 40 ⫹/14 years with no significant difference between CD and UC (age 43 ⫹/- 13 vs. 44.5 ⫹/- 14 respectively; p⫽0.5). Female patients with IBD were diagnosed at a significantly later age than male patients (46 ⫹/- 13 years vs. 40 ⫹/- 13 respectively; p⫽0.001). This trend remained significant for female patients with CD, UC and across each racial/ethnic group. Hispanic patients were diagnosed with UC more often than Caucasian patients (64% vs. 34%; OR 3.5; 95% CI⫽1.86.5, p⫽0.0003) or African Americans (64% vs. 43%; OR 2.3; 95% CI⫽1.3-4.3, p⫽0.005). Among the 147 patients with CD, 54% had fistulizing and/or stricturing disease. The prevalence of fistulizing, stricturing and inflammatory CD was similar across all age groups, gender and racial/ethnic groups. Conclusions: Female patients with UC and CD were diagnosed at a significantly older age than males across all racial/ethnic groups. UC was more common in Hispanics than other racial/ethnic groups. There was no difference in the CD phenotypes between the 3 racial/ethnic groups. This study failed to confirm the commonly held belief that African Americans with CD generally have more severe disease than Caucasians. Understanding the epidemiology of IBD and its sub-types requires studies examining the interactions between age, gender, race/ethnicity and socioeconomic status.
W1450 Serrated Adenomas of the Colon: Prevalence and Association With Neoplastic Lesions Carolina Fischer, Raquel Gonzalez, Lisandro Pereyra, Estanislao Gomez, Jose´ Mella, Adriana Mohaidle, Casas Gabriel, Pablo Luna, Silvia C. Pedreira, Daniel G. Cimmino, Luis A. Boerr Background: Serrated adenomas (SA) of the colon are thought to be precursor lesions of colorectal cancer through a different pathway than the classical sequence of adenoma-carcinoma. Their prevalence and malignant potential is not well defined.Aim: To determine the prevalence of SA in patients who underwent colonoscopy in a private community hospital, and the frequency of high grade dysplasia (HGD) and adenocarcinoma in these polyps. Moreover, to establish the association with synchronic and metachronic neoplastic lesions.Methods: Reports from patients undergoing colonoscopy and polypectomy from January 2003 to June 2008, were obtained from the electronic database of a private community hospital. SA were reanalyzed by a pathologist and classified based on the diagnostic criteria described by Snover. The prevalence of these polyps and the clinical and endoscopic features of the patients were determined. Synchronic lesions were defined by the presence of cancer and/or adenomas with or without advanced histologic features (AHF) (⬎1cm, HGD and/or 75% of villous component) in the same colonoscopy. Metachronic lesions were identified in patients who underwent surveillance colonoscopies, describing the time interval between studies. An univariate analysis was performed, looking for independent predictors for HGD and synchronic and metachronic neoplastic lesions in patients with SA.Results: 12693 colonoscopies were carried out in the analyzed period, identifying 116 patients with a total of 158 SA and a prevalence of 1.24%. 92.4% were sessile, 5.7% traditional and 1.9% non-classified SA. The mean age was 60; 56% were men. Most of the polyps were less than 1cm (81%) and sessile (80%), with predominant distribution in the rectosigmoid colon (52%). HGD was found in 8.2% of the SA, all of them in sessile serrated adenomas. No adenocarcinomas were identified.Synchronic lesions were found in 26% of the patients: 75% adenomas, 16% adenomas with AHF and 9% adenocarcinoma. 11% of the patients carried out surveillance colonoscopies within the first three years, 31% had metachronic lesions: SA (40%), adenomas (40%) and adenomas with AHF(20%). HGD and cancer were not found.We did not identify independent predictors for HGD and synchronic and metachronic neoplastic lesions in patients with SA.Conclusion: In the present study, the prevalence of SA was low, similar to that reported in the literature. We found a relevant association with neoplastic lesions; therefore, it is important to establish specific guidelines for the management of these kind of polyps.
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB331
W1444 Vascular Patterns Assessed by Vascular Analysis Software Are Predictive of Relapse in Patients With Inactive Ulcerative Colitis Toshiya Okahisa, Miho Tsuda, Tetsu Tomonari, Atsushi Inoue, Tetsuo Kimura, Shinji Kitamura, Hiromi Yano, Hisashi Takeuchi, Koichi Okamoto, Miyako Niki, Masako Kaji, Seisuke Okamura, Ryota Kanno, Shinsuke Konaka, Emoto Takahiro, Masatake Akutagawa, Tetsuji Takayama [Background] Mucosal healing has been incorporated in the assessment of treatment efficacy in the patient with ulcerative colitis (UC). However, there are some cases of endoscopically inactive mucosa which is inconsistent with histological activity and early recurrence in UC. In this study, we evaluated the usefulness of vascular pattern analysis using the vascular analysis software in order to evaluate the histological activity and predict the relapse in patients with inactive UC. [Methods] The mucosal vascular patterns in 214 colorectal segments of 28 patients with inactive UC were observed using conventional colonoscope (CF-H260AZI, Olympus, Tokyo, Japan). Vascular density (VD), number of intersection or diverging points (NID), and fractal dimension (FD) of the thick capillaries or veins in each segment were calculated using the vascular analysis software. Histological inflammation grades were also assessed in mucosal biopsy specimens. The patients were followed until relapse or for a maximum of 12 months. [Results] Positive correlations were identified among VD, NID, FD, and histological grade. Relapse rate was 21.4%. Multivaridate proportional hazard model analysis showed that VD, NID, and FD were significant predictor of relapse (relative risk: VD 1.63; NID 2.45; FD1.94). [Conclusion] Vascular pattern parameters assessed by vascular analysis software are associated with the degree of inflammation, and may predict the probability of subsequent relapse in patient with inactive ulcerative colitis.
W1445 Regional Differences in Colon Circumference and Wall Thickness Erick Salvatierra; Todd Spataro; Jaiyeola Thomas; Ankur Sheth; James Traylor; Long Jin; Anil Minoch; Jerry McLarty Introduction: It has been conventional teaching that electrosurgical intervention and mucosal polypectomy in the cecum and right colon are associated with higher risk of complications like perforation and post polypectomy syndrome secondary to relatively thin walled right colon compared to left colon. However, the published literature noting regional differences in the colon wall is sparse. In addition there is no data regarding gender differences in colon thickness.The aim of our study was to measure and document the differences in bowel wall thickness, layers and circumference in different parts of the colon. Materials and Methods: Twenty-five colon samples were studied from forensic and medical autopsy cases of deceased adults without significant bowel disease or abdominal trauma. Eleven sections were obtained from each colon and 3 mm sections were stained with Hematoxylin and Eosin stain. Layers of colonic wall in each section were measured using a micrometer with appropriate conversion factors on an Olympus microscope. Results: Colon samples from 19 males and 6 females with
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Volume 71, No. 5 : 2010
mean age of 38.48 years were evaluated. The mean circumference decreased progressively from proximal to distal colon (cecum 13.2 cm, rectum 6.6 cm; p⬍0.001). The mean colon wall thickness progressively increased from cecum to sigmoid colon (cecum: 1.17 mm, ascending colon: 1.42 mm, transverse colon: 1.48 mm, descending colon: 1.55 mm, sigmoid colon: 2.27 mm; P ⬍0.006 for cecum compared to sigmoid colon). There was statistically significant increase in thickness of mucosal layer (cecum 0.227 mm, rectum 0.363 mm, p⬍0.02) and muscularis propria (cecum 0.366 mm, rectum 1.09 mm; p⬍0.02) from cecum to rectum. Subset gender analysis showed that males had larger circumference of proximal colon (ascending colon 12.1 cm vs 7.7 cm; p⬍0.03) and females have thicker distal colon wall (sigmoid colon 1.53 mm vs 3.69 mm; p⬍0.001). Females were also noted to have thicker muscularis propria through out the colon (ascending colon: 0.64 vs 0.35 mm; p ⬍0.001, sigmoid colon: 1.44 mm vs 0.75 mm; p⬍0.022, rectum: 1.31 mm vs 0.88 mm; p⬍0.04). Conclusion: Our study shows that the cecum has the largest circumference in the colon. This may account for increased risk of perforation with barotrauma, pseudoileus and post obstructive distention based on Laplace’s law. The cecal wall is significantly thinner in full thickness as well in mucosal and muscularis propria layers. This may account for high risk of post polypectomy perforation and transmural burn injury.
W1446 Colorectal ESD; Treatment Results and Management of Complications Takemasa Hayashi, Hiroshi Kashida, Toshihisa Hosoya, Yoshiki Wada, Hideyuki Miyachi, Nobunao Ikehara, Fuyuhiko Yamamura, Kazuo Ohtsuka, Shin-Ei Kudo [Background]Endoscopic submucosal dissection (ESD) enables en-bloc resection of large neoplastic lesions in the gastrointestinal tract. En-bloc resection is particularly desirable in lesions suspicious of being invasive, because it allows precise histopathological evaluation which is important for preventing a recurrence and/or metastasis. Although ESD technique is almost established for the treatment of upper gastrointestinal (GI) neoplasia, it is not yet accepted as a standard treatment for colorectal lesions because of technical difficulty and complications. Thanks to recent the modification of dissecting knives and hemostatic forceps, advent of thicker solution for submucosal injection (ex. hyaluronic acid) and more sophisticated high-frequency generator, etc, ESD procedures are becoming safer and easier. The aim of this study is to clarify efficacy of ESD for the treatment of colorectal neoplasia.[Methods]We have treated 158 colorectal adenomas and early cancers with ESD technique since September 2003. Among them 90 lesions were treated during the recent one year, and these were evaluated in this study. The procedures were performed with endoscopes with water jet system (GIF-Q260J and PCF-Q260JI; Olympus) with CO2 insufflation instead of room air insufflation to reduce patient‘s discomfort. Glycerol and hyaluronate solution were used for injection to the submucosal layer. Erbotom ICC 200 (Erbe Elektromedizin Ltd) was used as a high⫺frequency generator. Knives used were Flush Knife (Fujinon;Tokyo) and Dual Knife(Olympus;Tokyo). Coagrasper (Olympus;Tokyo) was used for hemostasis. [Results] We assessed the rate of en bloc resection, complete resection and curative resection, adverse events and complications. The respective rates of en⫺bloc resection, complete resection (the horizontal and vertical margins are free of tumor) and curative resection were 95.6%, 93.3%, and 77.8%. Because of thin colorectal wall and limited maneuverability of the endoscope in the colorectum, proper muscle layer can receive damage easily. The moderate damage of the muscle layer occured during the procedure in 15 cases. These patients were observed carefully with conservative medical treatment after immediate closure of the tear with endo clips. There was no need for surgical intervention although, air leakage (perforation) was recognized with x-ray in one of them. No delayed perforation occurred. There was no bleeding after ESD [Conclusion] Advancement of devices has enabled easier and safer ESD procedure. Even if the muscle layer is damaged, immediate closure of the wound prevents significant perforation and emergent surgery.
W1447 Endoscopic Mucosal Resection and Modified Endoscopic Submucosal Dissection for Removal of Large Sessile Colonic Polyps: 1-Year Single Operator Experience in the USA Sergey V. Kantsevoy, Andrew Zhigalin Background: Development of endoscopic submucosal dissection (ESD) in Japan enabled endoscopic removal of large sessile and flat colonic polyps. However, ESD technique is difficult and requires accessories which are not readily available in the USA. Aim: To compare efficacy and safety of endoscopic mucosal resection (EMR) and modified ESD for removal of large flat colonic polyps. Methods: We performed retrospective chart review of all polypectomies performed at Mercy Medical Center from October 2008 till October 2009. Only patients with sessile and flat colonic polyps larger than 2 cm in diameter were included into this study. EMR was performed utilizing submucosal normal saline
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Abstracts injection and traditional lift-end-cut technique with a polypectomy snare. Modified ESD also required submucosal injections of normal saline followed by circumferential incision around the polyp made with the tip of a polypectomy snare. Then the snare was placed into the incision surrounding the polyp, tightened, and electrical current was applied to cut off the polyp. A follow-up colonoscopy in 3-6 months was recommended to all patients to rule out any residual polypoid tissue at the polypectomy site. Results: Large sessile and flat colonic polyps were endoscopically removed in 67 patients. In 34 patients the polyps were removed by EMR and in 33 patients the polyps were removed by modified ESD. Both groups were similar by the mean age of the patients (62.0⫾12.6 and 65.0⫾11.6), the size of the polyps (2.9⫾1.0 cm versus 2.9⫾0.9 cm), and the presence of malignancy (5 patients with high grade dysplasia [14.7% and 15.2%] and 2 patients with adenocarcinoma [5.9% and 6.1%] in each group). EMR required significantly less fluid for submucosal injection comparing with modified ESD (26.8⫾14.3 cc vs 40.0⫾16.3 cc, P⫽0.0008), Delayed bleeding occurred in 2 patients (5.9%) post EMR but only in 1 patient (3.0%) post modified ESD. There was 1 perforation post EMR (2.9%) and no perforations post modified ESD. Repeat colonoscopy was performed in 13 patients (38.2%) post EMR and in 15 patients (45.5%) post modified ESD. In 3 patients post EMR residual polypoid tissue was found and successfully removed from the previous polypectomy sites. There was no residual polypoid tissue found in any patients who had modified ESD. Conclusion: For endoscopic removal of large sessile colonic polyps modified ESD appears safer and provides better results comparing with traditional EMR.
W1448 Risk Factors and Prediction of Ischemic Colitis vs. Diverticulosis As the Cause of Severe Hematochezia Using Multivariate Analysis and Classification Tree Modeling Disaya Chavalitdhamrong, Dennis M. Jensen, Daniella Markovic, Jeffrey Gornbein, Mary Ellen Jensen, Nan Sun Both diverticulosis (TICS) & ischemic colitis (IC) are common causes of severe hematochezia (LGIB). Accurately predicting the diagnosis of IC vs. TICS early from clinical parameters could improve treatments & outcomes. PURPOSE: To assess clinical risk factors for predicting IC vs TICS and develop a predictive algorithm. METHODS:. A CURE DDRC data base of 208 consecutive patients in the last 12 years with LGIB from colonic causes was used and analyzed using both backward logistic regression (LR) & classification tree (CT) models. All patients had urgent colonoscopy after PEG-based oral purges. RESULTS: Table 1 shows additive logistic model risk factors of IC. For the CT, 5 variables were used: outpatient start of bleed vs. inpatient start, age, black, prognosis score (prog #), & PTT (sec). (Renal severity was borderline). In CT, odds of IC vs. TICS was highest in inpatient bleed (OR⫽4.91, p⫽0.000). Next highest risk were nonblack outpatients ⬍75 yrs old, prog #⬍3.5 & PTT⬎24.7scc (OR⫽2.81, p⫽0.0017). Those non-black outpatients with prog #⬍3.5, and PTT⬍24 were more likely to be TICS (OR for IC⫽0.40, p⫽0.23) as were non-black outpatients ⬍ 75 yrs old with prog # ⬎ 3.5 (OR⫽0.0 , p⫽0.079). Black outpatients ⬍ 75 years were also more likely to have TICS (OR⫽0.287, p⫽0.041) as was any outpatient over age 75 (OR⫽0.248, p ⫽ 0.0006). Overall accuracy of LR vs. CT was 77% vs. 79%; sensitivity for ischemia was 70.8% vs. 80%.; specificity for TICS was 83% vs. 78%; & concordance (ROC area) was 0.84 vs. 0.81. CONCLUSIONS: 1) Clinical parameters can predict whether IC or TICS is the cause of LGIB. 2) Independent predictors of IC are inpatient start of bleeding, non-black race & female gender; predictors of TIC hemorrhage are older age, black race, & higher prognosis score. 3) Classification tree & logistic models were similar in accuracy, sensitivity & concordance. These results may be useful clinically to predict IC or TICS as the cause of severe LGIB. Supported in part by NIH Grants (K24-DK002650) & CURE Human Studies Core (P30DK041301). Table 1: Logistic Regression for IC vs. TICS Inpatient vs. Outpatient Start of Bleed Other Race vs. Black Renal Disease Female vs. Male Age (per year) Heart Disease (Moderate/ Severe vs. Mild/None) Prognostic Score (per unit)
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Odds Ratio
Lower CI
Upper CI
P-Value
8.26
3.01
22.73
⬍0.0001
4.08 3.42 2.65 0.94 2.49
1.45 1.21 1.24 0.91 0.97
11.49 9.67 5.66 0.98 6.39
0.008 0.020 0.012 0.0005 0.059
0.71
0.49
1.04
0.075
W1449 Epidemiology of the Phenotypes of Inflammatory Bowel Disease Among an Indigent Multi-Ethnic Patient Population in the United States Hoda M. Malaty, Jason Hou, Selvi Thirumurthi Background: There is a paucity of data on the epidemiologic features and clinical manifestations of inflammatory bowel disease (IBD) among patients of low socioeconomic status in the United States. Aim: To examine and compare the epidemiologic features of IBD among African American, Hispanic and Caucasian patients from a County Hospital where the majority of the patients are socioeconomically disadvantaged. Methods: A retrospective investigation was conducted on a cohort of adult patients diagnosed with IBD based on clinical, radiologic, endoscopic and histologic data. The study reviewed charts of adults aged 20 to 70 suspected of having IBD between 2000 and 2006. Demographic data, disease sub-type and phenotypic features of IBD were recorded. The data were analyzed using the Chi-square, Fisher exact and Student t-tests. Results: The study cohort included 279 patients with 54% female, 30% Caucasian, 44% African American and 26% Hispanic. Over half of the patients had Crohn’s disease (CD, 54%) and 46% had ulcerative colitis (UC). The mean age at diagnosis was 40 ⫹/14 years with no significant difference between CD and UC (age 43 ⫹/- 13 vs. 44.5 ⫹/- 14 respectively; p⫽0.5). Female patients with IBD were diagnosed at a significantly later age than male patients (46 ⫹/- 13 years vs. 40 ⫹/- 13 respectively; p⫽0.001). This trend remained significant for female patients with CD, UC and across each racial/ethnic group. Hispanic patients were diagnosed with UC more often than Caucasian patients (64% vs. 34%; OR 3.5; 95% CI⫽1.86.5, p⫽0.0003) or African Americans (64% vs. 43%; OR 2.3; 95% CI⫽1.3-4.3, p⫽0.005). Among the 147 patients with CD, 54% had fistulizing and/or stricturing disease. The prevalence of fistulizing, stricturing and inflammatory CD was similar across all age groups, gender and racial/ethnic groups. Conclusions: Female patients with UC and CD were diagnosed at a significantly older age than males across all racial/ethnic groups. UC was more common in Hispanics than other racial/ethnic groups. There was no difference in the CD phenotypes between the 3 racial/ethnic groups. This study failed to confirm the commonly held belief that African Americans with CD generally have more severe disease than Caucasians. Understanding the epidemiology of IBD and its sub-types requires studies examining the interactions between age, gender, race/ethnicity and socioeconomic status.
W1450 Serrated Adenomas of the Colon: Prevalence and Association With Neoplastic Lesions Carolina Fischer, Raquel Gonzalez, Lisandro Pereyra, Estanislao Gomez, Jose´ Mella, Adriana Mohaidle, Casas Gabriel, Pablo Luna, Silvia C. Pedreira, Daniel G. Cimmino, Luis A. Boerr Background: Serrated adenomas (SA) of the colon are thought to be precursor lesions of colorectal cancer through a different pathway than the classical sequence of adenoma-carcinoma. Their prevalence and malignant potential is not well defined.Aim: To determine the prevalence of SA in patients who underwent colonoscopy in a private community hospital, and the frequency of high grade dysplasia (HGD) and adenocarcinoma in these polyps. Moreover, to establish the association with synchronic and metachronic neoplastic lesions.Methods: Reports from patients undergoing colonoscopy and polypectomy from January 2003 to June 2008, were obtained from the electronic database of a private community hospital. SA were reanalyzed by a pathologist and classified based on the diagnostic criteria described by Snover. The prevalence of these polyps and the clinical and endoscopic features of the patients were determined. Synchronic lesions were defined by the presence of cancer and/or adenomas with or without advanced histologic features (AHF) (⬎1cm, HGD and/or 75% of villous component) in the same colonoscopy. Metachronic lesions were identified in patients who underwent surveillance colonoscopies, describing the time interval between studies. An univariate analysis was performed, looking for independent predictors for HGD and synchronic and metachronic neoplastic lesions in patients with SA.Results: 12693 colonoscopies were carried out in the analyzed period, identifying 116 patients with a total of 158 SA and a prevalence of 1.24%. 92.4% were sessile, 5.7% traditional and 1.9% non-classified SA. The mean age was 60; 56% were men. Most of the polyps were less than 1cm (81%) and sessile (80%), with predominant distribution in the rectosigmoid colon (52%). HGD was found in 8.2% of the SA, all of them in sessile serrated adenomas. No adenocarcinomas were identified.Synchronic lesions were found in 26% of the patients: 75% adenomas, 16% adenomas with AHF and 9% adenocarcinoma. 11% of the patients carried out surveillance colonoscopies within the first three years, 31% had metachronic lesions: SA (40%), adenomas (40%) and adenomas with AHF(20%). HGD and cancer were not found.We did not identify independent predictors for HGD and synchronic and metachronic neoplastic lesions in patients with SA.Conclusion: In the present study, the prevalence of SA was low, similar to that reported in the literature. We found a relevant association with neoplastic lesions; therefore, it is important to establish specific guidelines for the management of these kind of polyps.
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB331