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W1473: Colonic Stents: Which Factors Influence Technical and Clinical Success?
Abstracts W1472 Colonic Investigations for Isolated Abdominal Pain: Endoscopy or CT Colonography? Christian P. Selinger, Javaid Iqbal, Lolita Chan, Robert P. Willert, Simon Campbell Background & Aim:Abdominal pain is often seen as a weak indication for colonic investigations. The yield of serious pathology detected by colonoscopy has differed greatly (2.5% - 17.1%) in published series.1, 2 The introduction of CT colonography (CTC) offers a less invasive way of colonic investigation with a significantly lower perforation risk compared to colonoscopy. The aim of this study was to establish and compare the yield of colonoscopies and CTC performed in our hospital for isolated abdominal pain. Method:We retrospectively analysed data from the endoscopy database for all colonoscopies performed between January 2000 and December 2008 and from the radiology database for CT colonographies performed between January and December 2008. The yield for detection of pathology (colonic polyps, cancers and inflammatory bowel disease [IBD]) was recorded for abdominal pain as the sole indication. Data was analysed using chi-square test and Fisher’s exact test. Statistical significance was taken at p⬍0.05.Results:While 5.4% of 8564 colonoscopies were undertaken for abdominal pain, the proportion (8.2%) of 525 CTC undertaken for abdominal pain was significantly greater (p⫽0.0062). Patients undergoing CTC were significantly older (60 versus 48 years; p⬍0.0001). The yield of overall and individual pathology detection was not significantly different for both investigations (P⫽NS). CTC also detected 10 extra-colonic incidental findings in 23.3% of patients.Conclusion:Colonic investigations undertaken for abdominal pain had a surprisingly high yield of incidental colonic pathology (polyps) at our institution. The detection of these polyps could be beneficial but does not explain the patients’ symptoms. CTC offers a less invasive way of detecting colonic pathology in patients with isolated abdominal pain while maintaining the same yield. It could therefore spare 75% of patients a colonoscopy. Detection of extra-intestinal pathology is an additional bonus of CTC when investigating isolated abdominal pain.References:1. Yee KC, Cello JP, Ostroff J. Diagnostic Yield of Colonoscopy for the Evaluation of Isolated Abdominal Pain. Gastrointest Endoscopy 2004; 59: p1362. Powell N, Dunn J, Treibel TA et al. Appropriateness of Colonoscopy for Patients with Isolated Abdominal Pain. Gastrointest Endoscopy 2008; 67: AB322 nⴝ colonoscopy CTC chi-square
461 43 p⫽0.0062
% of total normal colon 5.4% 8.2% p⫽NS
76.13% 79.07% p⫽NS
IBD
polyps carcinoma
4.99% 16.05% 2.33% 18.6% p⫽NS p⫽NS
2.82% 0% p⫽NS
W1473 Colonic Stents: Which Factors Influence Technical and Clinical Success? Christian P. Selinger, Jayapal Ramesh, Derrick F. Martin Introduction: Stent insertion for colonic obstruction has developed at a relatively slow pace. Aims & Methods: To ascertain factors influencing technical and clinical outcomes of colonic stent insertion in our tertiary referral centre. Patients who underwent colonic SEMS insertion between 2000 and 2008 were identified from our prospective stent database. Additional data was collected from case notes. Technical success was defined as correct stent placement, clinical shortterm success as clinical improvement for at least 5 days and long term clinical success as absence of the need for re-intervention until death or end of followup. Follow up was until need for re-intervention, death or for a minimum of 6 months.Results: 104 SEMS were attempted in 96 patients (mean age 72.3 years [36-97 years]; 47% male) with a technical success rate of 83.3% and a clinical short-term success rate of 77.1%. Indications were colonic malignancy (80.2%), extra-colonic malignancy (14.6%) and others (5.2%). Multiple logistic regression analysis showed that age, sex, indication and site did not influence technical success and short term clinical success. Year of insertion had a significant independent relationship with success (p⫽0.041). Stent insertions attempted at the end of study period were less likely to be successful. Long-term follow-up data for a median of 6 months (range 1-72 months) was available on 57 patients. Clinical long-term success was observed in 77%. 9 patients were successfully bridged to radical surgery. Of 48 patients for whom the stent was aimed to be the sole long-term treatment 35 (73%) required no further intervention. Age, sex, site, year of insertion, type and length of stent did not influence long-term clinical success. SEMS insertion for patients with colonic malignancy had significantly higher success rates (81%) compared to those with extra-colonic malignancies (43%) (p⫽0.049). Early and late complications occurred in 8 (8.3%) and 15 (26.3%) cases. Conclusion: Stent insertion relieves symptoms of colonic obstruction in the vast majority of patients. Successfully placed stents maintain symptom relief in over 70% for a mean of 15 months. The decline in technical success rate is likely due to a widened scope of referrals and attempts in more complex cases. Complications rates are however high and a significant minority requires re-intervention. Obstruction caused by extra-colonic malignancies is far less likely to be permanently palliated by SEMS in comparison to colonic malignancies.
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W1474 Pneumoretoroperitoneum and Pneumoperitoneum Detected by CT After Endoscopic Submucosal Dissection for Colorectal Tumors in Consecutive Cases Hiroshi Araki, Yohei Horibe, Fumito Onogi, Takashi Ibuka, Hisataka Moriwaki, Jun Takada, Shinji Nishiwaki BACKGROUND: ESD has the advantage over conventional endoscopic mucosal resection. ESD are now being increasingly used for the treatment of gastric cancers. However, colorectal wall is very thin and there is no serous membrane in rectal wall. If there is small injury of muscularis propria of rectum, easily pneumoretoroperitoneum is occurred. The procedure needs a higher quality of skill for colorectal tumors. AIM: We evaluated the clinical outcome of ESD for colorectal tumors, and the frequency of post operative small pneumoretoroperitoneum and small pneumoperitoneum detected by CT. PATIENTS AND METHODS: From June 2006 to September 2009, 157 consecutive patients underwent endoscopic submucosal dissection for colorectal tumors, and their clinical outcomes were evaluated in our institution. In these patients, we evaluated post operative small pneumoretoroperitoneum and small pneumoperitoneum by CT. The using device for ESD were B-Knife alone (31 cases), Flex-Knife (93 cases), and Dual -Knife(33 cases). And ESD procedures performed by using sodium hyaluronate. Indications were tublar adenoma (52cases), seratted adenoma (4 cases), adenocarcinoma (86cases), carcinoid tumor (15case). MAIN OUTCOME MEASUREMENTS: The en bloc resection rate, complications, total operation time, recurrence rate and frequency of postoperative small pneumoretoroperitoneum and small pneumoperitoneum detected by CT were also evaluated within 30minitues after ESD. RESULTS: The rates of en bloc resection and rates of of en bloc plus R0 resection of ESD were 97.2% (138 of 142) and 82.4%(117 of 142) in cases of adenoma and adenocarcinoma, and 100% (15 of 15) and 80% (12 of 15) in cases of carcinoid tumor. Mean operation time ware 51.3 minutes in cases of adenoma and adenocarcinoma, 17 minitues in cases of carcinoid tumor. Post operative bleeding occurred in 12 cases(7.6%). Perforation during ESD occurred 1 case(0.6%) who was managed with emergency operation. 27cases had postoperative small pneumoretoroperitoneum and small pneumoperitoneum detected by CT (19%) in cases of adenoma and adenocarcinoma. 3 cases had in cases of carcinoid tumor(21.4%). They were managed with conservative medical treatment after endoscopic closure of the perforation. Hospitalization were not significantly different. Excluding 12 patients in whom additional surgery was carried out, all of 145 patients were free of recurrence.CONCLUSION: ESD can be safely performed for colorectal tumors, resulting in a high en bloc resection rate. But ESD for colorectal tumors has a relatively high rate of postoperative pneumoretoroperitoneum and pneumoperitoneum, so should only be performed by experienced endoscopists.
W1475 Predicting Rectal Cancer T Stage Using Circumferential Tumor Extent Kazutomo Togashi, Hisanaga Horie, Kenichi Utano, Shigeki Kijima, Hidetoshi Kumano, Yasuyuki Miyakura, Alan Lefor, Yoshikazu Yasuda PURPOSE: Patients with stage T3/T4 rectal cancer are candidates for neoadjuvant chemo-radiation therapy. We undertook this study to clarify the usefulness of the circumferential tumor extent (CTE) in differentiating T3/T4 from T1/T2 rectal cancer.METHODS: Consecutive rectal cancer patients (n⫽137) who underwent curative-intent surgery from January 2005 to July 2009 were enrolled. Patients who received preoperative radiation were excluded. All patients underwent colonoscopy and subsequently CT colonography (CTC) on the same day. Colonoscopy was performed using standard techniques, and CTE was determined by a single colonoscopist. CTC was performed in the prone position. A single radiologist determined CTE without knowing the results of the colonoscopy, and was estimated in 10% increments. Pathological T stage was used as the reference. To measure the inter-observer agreement, one independent colonoscopist and one radiologist reviewed all 137 lesions.RESULTS: The median (95%ile) CTE evaluated by colonoscopy was 20%(10-20) for T1(n⫽15), 30%(20-30) for T2(n⫽43), 50%(40-80) for T3(n⫽32) and 90%(73-100) for T4(n⫽47). CTC showed 10%(10-20), 30%(20-30), 50%(30-60) and 80% (70-100), respectively. Using both modalities, there was a significant difference between T1/T2 and T3/T4 (p⬍0.0001, Mann-Whitney). The correlation coefficient between colonoscopy and CTC was very high (0.94). By defining CTE ⱖ 50% by colonoscopy as the criteria for stage T3/T4, the sensitivity, specificity, positive predictive value and negative predictive values were 73%, 93%, 94%, and 72%. Regarding CTC, these diagnostic values were 74%, 86%, 88%, and 71%, respectively. Kappa values (95% CI) were 0.84 (0.67-1.00) for colonoscopy and 0.90 (0.73-1.00) for CTC, suggesting excellent agreement.CONCLUSIONS: Circumferential tumor extent ⱖ50% is a simple and reliable marker to identify candidates for neo-adjuvant chemo-radiation therapy. In particular, the positive predictive value is excellent. Because the negative predictive value is not acceptable, patients with ⬍50% circumferential extent should be examined by additional modalities.
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB337
461 43 p⫽0.0062
% of total normal colon 5.4% 8.2% p⫽NS
76.13% 79.07% p⫽NS
IBD
polyps carcinoma
4.99% 16.05% 2.33% 18.6% p⫽NS p⫽NS
2.82% 0% p⫽NS
W1473 Colonic Stents: Which Factors Influence Technical and Clinical Success? Christian P. Selinger, Jayapal Ramesh, Derrick F. Martin Introduction: Stent insertion for colonic obstruction has developed at a relatively slow pace. Aims & Methods: To ascertain factors influencing technical and clinical outcomes of colonic stent insertion in our tertiary referral centre. Patients who underwent colonic SEMS insertion between 2000 and 2008 were identified from our prospective stent database. Additional data was collected from case notes. Technical success was defined as correct stent placement, clinical shortterm success as clinical improvement for at least 5 days and long term clinical success as absence of the need for re-intervention until death or end of followup. Follow up was until need for re-intervention, death or for a minimum of 6 months.Results: 104 SEMS were attempted in 96 patients (mean age 72.3 years [36-97 years]; 47% male) with a technical success rate of 83.3% and a clinical short-term success rate of 77.1%. Indications were colonic malignancy (80.2%), extra-colonic malignancy (14.6%) and others (5.2%). Multiple logistic regression analysis showed that age, sex, indication and site did not influence technical success and short term clinical success. Year of insertion had a significant independent relationship with success (p⫽0.041). Stent insertions attempted at the end of study period were less likely to be successful. Long-term follow-up data for a median of 6 months (range 1-72 months) was available on 57 patients. Clinical long-term success was observed in 77%. 9 patients were successfully bridged to radical surgery. Of 48 patients for whom the stent was aimed to be the sole long-term treatment 35 (73%) required no further intervention. Age, sex, site, year of insertion, type and length of stent did not influence long-term clinical success. SEMS insertion for patients with colonic malignancy had significantly higher success rates (81%) compared to those with extra-colonic malignancies (43%) (p⫽0.049). Early and late complications occurred in 8 (8.3%) and 15 (26.3%) cases. Conclusion: Stent insertion relieves symptoms of colonic obstruction in the vast majority of patients. Successfully placed stents maintain symptom relief in over 70% for a mean of 15 months. The decline in technical success rate is likely due to a widened scope of referrals and attempts in more complex cases. Complications rates are however high and a significant minority requires re-intervention. Obstruction caused by extra-colonic malignancies is far less likely to be permanently palliated by SEMS in comparison to colonic malignancies.
www.giejournal.org
W1474 Pneumoretoroperitoneum and Pneumoperitoneum Detected by CT After Endoscopic Submucosal Dissection for Colorectal Tumors in Consecutive Cases Hiroshi Araki, Yohei Horibe, Fumito Onogi, Takashi Ibuka, Hisataka Moriwaki, Jun Takada, Shinji Nishiwaki BACKGROUND: ESD has the advantage over conventional endoscopic mucosal resection. ESD are now being increasingly used for the treatment of gastric cancers. However, colorectal wall is very thin and there is no serous membrane in rectal wall. If there is small injury of muscularis propria of rectum, easily pneumoretoroperitoneum is occurred. The procedure needs a higher quality of skill for colorectal tumors. AIM: We evaluated the clinical outcome of ESD for colorectal tumors, and the frequency of post operative small pneumoretoroperitoneum and small pneumoperitoneum detected by CT. PATIENTS AND METHODS: From June 2006 to September 2009, 157 consecutive patients underwent endoscopic submucosal dissection for colorectal tumors, and their clinical outcomes were evaluated in our institution. In these patients, we evaluated post operative small pneumoretoroperitoneum and small pneumoperitoneum by CT. The using device for ESD were B-Knife alone (31 cases), Flex-Knife (93 cases), and Dual -Knife(33 cases). And ESD procedures performed by using sodium hyaluronate. Indications were tublar adenoma (52cases), seratted adenoma (4 cases), adenocarcinoma (86cases), carcinoid tumor (15case). MAIN OUTCOME MEASUREMENTS: The en bloc resection rate, complications, total operation time, recurrence rate and frequency of postoperative small pneumoretoroperitoneum and small pneumoperitoneum detected by CT were also evaluated within 30minitues after ESD. RESULTS: The rates of en bloc resection and rates of of en bloc plus R0 resection of ESD were 97.2% (138 of 142) and 82.4%(117 of 142) in cases of adenoma and adenocarcinoma, and 100% (15 of 15) and 80% (12 of 15) in cases of carcinoid tumor. Mean operation time ware 51.3 minutes in cases of adenoma and adenocarcinoma, 17 minitues in cases of carcinoid tumor. Post operative bleeding occurred in 12 cases(7.6%). Perforation during ESD occurred 1 case(0.6%) who was managed with emergency operation. 27cases had postoperative small pneumoretoroperitoneum and small pneumoperitoneum detected by CT (19%) in cases of adenoma and adenocarcinoma. 3 cases had in cases of carcinoid tumor(21.4%). They were managed with conservative medical treatment after endoscopic closure of the perforation. Hospitalization were not significantly different. Excluding 12 patients in whom additional surgery was carried out, all of 145 patients were free of recurrence.CONCLUSION: ESD can be safely performed for colorectal tumors, resulting in a high en bloc resection rate. But ESD for colorectal tumors has a relatively high rate of postoperative pneumoretoroperitoneum and pneumoperitoneum, so should only be performed by experienced endoscopists.
W1475 Predicting Rectal Cancer T Stage Using Circumferential Tumor Extent Kazutomo Togashi, Hisanaga Horie, Kenichi Utano, Shigeki Kijima, Hidetoshi Kumano, Yasuyuki Miyakura, Alan Lefor, Yoshikazu Yasuda PURPOSE: Patients with stage T3/T4 rectal cancer are candidates for neoadjuvant chemo-radiation therapy. We undertook this study to clarify the usefulness of the circumferential tumor extent (CTE) in differentiating T3/T4 from T1/T2 rectal cancer.METHODS: Consecutive rectal cancer patients (n⫽137) who underwent curative-intent surgery from January 2005 to July 2009 were enrolled. Patients who received preoperative radiation were excluded. All patients underwent colonoscopy and subsequently CT colonography (CTC) on the same day. Colonoscopy was performed using standard techniques, and CTE was determined by a single colonoscopist. CTC was performed in the prone position. A single radiologist determined CTE without knowing the results of the colonoscopy, and was estimated in 10% increments. Pathological T stage was used as the reference. To measure the inter-observer agreement, one independent colonoscopist and one radiologist reviewed all 137 lesions.RESULTS: The median (95%ile) CTE evaluated by colonoscopy was 20%(10-20) for T1(n⫽15), 30%(20-30) for T2(n⫽43), 50%(40-80) for T3(n⫽32) and 90%(73-100) for T4(n⫽47). CTC showed 10%(10-20), 30%(20-30), 50%(30-60) and 80% (70-100), respectively. Using both modalities, there was a significant difference between T1/T2 and T3/T4 (p⬍0.0001, Mann-Whitney). The correlation coefficient between colonoscopy and CTC was very high (0.94). By defining CTE ⱖ 50% by colonoscopy as the criteria for stage T3/T4, the sensitivity, specificity, positive predictive value and negative predictive values were 73%, 93%, 94%, and 72%. Regarding CTC, these diagnostic values were 74%, 86%, 88%, and 71%, respectively. Kappa values (95% CI) were 0.84 (0.67-1.00) for colonoscopy and 0.90 (0.73-1.00) for CTC, suggesting excellent agreement.CONCLUSIONS: Circumferential tumor extent ⱖ50% is a simple and reliable marker to identify candidates for neo-adjuvant chemo-radiation therapy. In particular, the positive predictive value is excellent. Because the negative predictive value is not acceptable, patients with ⬍50% circumferential extent should be examined by additional modalities.
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB337