Benign Colonic Polyps Research Articles

Analysis of the outcomes of postdiverticulitis investigations: a multicentre cohort study including 1,120 patients.

The aim of this study was to assess the yield of the endoscopic investigations performed following the resolution of acute diverticulitis. A retrospective multicentre study included patients with multislice computed tomography (MSCT)-proven diverticulitis, in four NHS hospitals, between January 2016 and April 2023. The primary outcome was the rate of colonic cancer in the diseased segment. Secondary outcomes included the rate of malignancy in the nondiseased colonic segments, the benign colonic polyp detection rate, the rate of malignancy in the resected surgical specimens in patients who underwent an emergency surgery on the index admission and the rate of complications in the investigated group. A total of 1,120 patients were included in the study, out of which 604 were females, with a median age of 61 years; 731 patients (65%) had uncomplicated diverticulitis (Hinchey 1A) while 389 (35%) had complicated diverticulitis (Hinchey 1B-4). Following the acute episode, 757 (74%) patients had subsequent endoscopic evaluation. The incidence of colorectal cancer (CRC) or advanced adenomas (AA) in patients with uncomplicated diverticulitis was 0.14%. In the complicated diverticulitis group, the incidence of CRC/AA in patients with Hinchey 1b and Hinchey 2 was 1.4% and 5.4%, respectively. Out of the 102 patients who underwent emergency colonic resection for suspected perforated diverticulitis, 18 (17.6%) had histological evidence of colonic malignancy. Endoscopic investigations following uncomplicated diverticulitis have a low yield for sinister colonic pathology. Colonoscopy should be planned following complicated diverticulitis and in patients with uncomplicated diverticulitis with suspicious radiological finding on index imaging or in patients with ongoing clinical manifestations. In patients who undergo emergency surgery, oncological principles should be applied whenever possible.

Concordance Rate of Pre-Operative Radiological Stage with Postoperative Pathological Stage in Colon Cancer

Aim: This study aimed to assess the concordance rate between pre-operative radiological staging using CT imaging and postoperative pathological staging in patients with colon cancer. Methodology: A prospective observational study was conducted at the Oncology Department of Jinnah Postgraduate Medical Center, Pakistan, with ethical committee approval between February 2023 to July 2023. Inclusion criteria involved patients diagnosed with colon adenocarcinoma aged >18 receiving treatment at the center, while exclusion criteria comprised unconfirmed colon cancer, lack of consent, benign colonic polyps, metastatic cancer, chemotherapy recipients, and incomplete data. Sample size estimation yielded 227 patients. Recruitment used consecutive sampling, and data were collected using a predefined proforma. CT scans were performed, and T-stage was assessed by radiologists and pathologists. Histological analysis followed established guidelines, with final pathology serving as the gold standard. Results: The diagnostic accuracy of CT imaging was evaluated, with statistically significant concordance found between CT scans and histopathological diagnoses (p-value = 0.046). CT scans demonstrated a sensitivity of 57.14% for Stage I tumors and a specificity of 88.18% for Stage II-III tumors. The positive predictive value (PPV) was 13.3%, and the negative predictive value (NPV) was 98.48%, resulting in an overall accuracy of 87.22%. These findings suggest that CT imaging is valuable for identifying Stage II-III tumors, exhibiting good specificity and NPV, although sensitivity and PPV for Stage I tumors were comparatively lower. Chi-square testing confirmed the statistical significance of these results (p-value ≤ 0.05) Conclusion: This study highlights the utility of CT imaging in pre-operative staging of colon cancer, particularly for Stage II-III tumors, where it exhibits notable accuracy. However, improvements may be needed to enhance sensitivity and PPV for Stage I tumors. Keywords: Colon cancer, CT imaging, pathological staging, concordance rate, diagnostic accuracy.

FRI643 Tirzepatide Associated Partial Small Bowel Obstruction: A Case Report

Abstract Disclosure: A. Mathew: None. H. Hannoodee: None. Glucagon-like peptide-1 receptor agonists (GLP1 RA) are quickly becoming an adjunctive treatment modality for people with type-2 diabetes and is approved for chronic weight management. Tirzepatide has a dual GIP/GLP-1 RA action and has a synergistic effect when administered together. GLP-1 RA are associated with improved cardiovascular and all-cause mortality outcomes in patients with type-2 diabetes. Tirzepatide is associated with gastrointestinal (GI) side effects like nausea, diarrhea, abdominal pain, decreased appetite, and constipation. This case report discusses a case of small bowel obstruction (SBO) that was noted after patient was changed from dulaglutide to tirzepatide. Mr. X is a 61 y/o male with PMHx of type-2 DM, HTN, and HLD who presented to ER for severe epigastric pressure- like 7/10 abdominal pain. No association with food intake. He had 1 episode of semi-loose stools. Denied any abdomen cramping, sick contacts, nausea/vomiting, fever/chills, or constipation. His previous endoscopy was only relevant for benign colonic polyps, which were removed. He had been on GLP1 RA for more than a year, and previously on dulaglutide 3mg, which was switched to tirzepatide 2.5mg 5 weeks ago. He was able to tolerate the medication without significant side effects and was recently up-titrated to 5 mg. Labs showed WBC 7.2, Hb 13.6, Cr 1.45, BUN 12, lipase 25, and normal LFTs. Abdominal X-ray and CT abdomen were noted to be significant for a partial vs evolving SBO without any identifiable small bowel intrinsic pathology. Mr. X was managed conservatively with fluids, NPO diet, and pain medications. Serial abdominal images were obtained, and he was eventually advanced to soft diet. Tirzepatide was discontinued on discharge. As a response to enteral nutrition, distal small bowel and colon release GLP-1 hormone. Exogenous and endogenous GLP-1 are associated with reduced gastric motility. GLP 1 RA and dual GIP/GLP-1 RA are advised to be used with caution in patients with established gastroparesis, as they can worsen the symptoms. GLP-1 effect on small intestinal motility is not extensively studied, however, small bowel motility inhibition was noted in animal models. Some of these actions were dose-dependent. There are some case reports of SBO due to GLP-1 RA. An observational cohort study noted an increased incidence of SBO with GLP1 RA when compared to SGLT2i. They noted most incidents of SBO happened early within the initiation of therapy (within 3 months). At the time of writing this abstract, there are no published SBO case reports associated with tirzepatide. Further large-scale clinical trials need to be conducted to explore the association of SBO in patients with GIP/GLP-1 and GLP-1 RA. These studies will help guide if these drugs should be contraindicated or used with caution in people with a previous history of SBO or colonic obstruction. Presentation: Friday, June 16, 2023

#3741 A CASE OF PODOCYTIC INFOLDING GLOMERULOPATHY WITH DIABETES MELLITUS, NEPHROTIC RANGE PROTEINURIA AND POSITIVE ANTI-PLA2R IN SERUM

Abstract Background and Aims Podocytic infolding glomerulopathy (PIG) is a rare glomerular abnormality which was first proposed as a new disease entity in 2008. It is characterized by glomerular basement membrane (GBM) bubbling viewable by light microscopy, due to extensive trapping of podocytic cytoplasm fragments and cell membrane projections within the GBM. Electron microscopy reveals podocyte infolding and invagination into the glomerular basement membranes (GBMs). Most of the cases reported worldwide, indicate that PIG usually co-exists with autoimmune diseases. In this case we present a diabetic patient with no other autoimmune disease in his medical history, whose biopsy was characterized as PIG. Method A 60-year-old Caucasian man with a 5-year history of type II diabetes mellitus, hyperlipidemia, hypertension, hyperuricemia and benign colon polyps, was noted by his family physician to have proteinuria. He had been treated with an angiotensin II receptor blocker, statin, and allopurinol for 5 years and he was well regulated. At the point of admission, his 24-h urine collection showed 4,5gr of urine protein. His creatinine at the time was normal (0,89mg/dl), no hypoalbuminemia, no edema or deregulation of hyperlipidemia was noted. His fundoscopy at this point had no diabetic lesions. In the immunological work up, we found normal values of autoantibodies ANA, anti-dsDNA, anti-ENA, complement screening C3, C4, serum and urine protein electrophoresis - immunofixation. Everything was within normal limits except from serum autoantibodies to Phospholipase A2 Receptor of podocytes which was tested with ELISA and valued 35 RU/mL (<20RU/mL). In the following 9 months his proteinuria remained at the same levels. Due to the persistent nephrotic range proteinuria (>3.5gr/24h) a kidney biopsy was performed. Biopsy was evaluated under light microscope (histochemistry for Congo-Red and immunohistochemistry for C4d, PLA2R and DNAJB9 included), immunofluorescence and electron microscope. Results The renal biopsy included 8 glomeruli, 3 of them globally sclerosed (37.5%), the rest enlarged with mild to moderate mesangial matrix increase and thickening of the GBMs, without spikes, pin holes or reduplications. Immunohistochemistry for C4d, PLA2R and DNAJB9 was negative. Immunofluorescence revealed nothing noticeable (no staining of IgG, IgA, IgM, C3, C1q, C4, κ-λ chains) apart from a moderate linear albumin staining. Without electron microscopy the whole picture was rather reminiscent of mild to moderate lesions of diabetic nephropathy. On electron microscopy, no classical electron-dense deposits were found. Effacement of podocytes’ foot processes was multi-segmental. More importantly, podocytic cytoplasmic processes invaginating into the GBMs were observed, accompanied by scattered endomembranous, partially microspherular microstructures, sometimes with adjacent unclear small pyknotic areas. The biopsy report concluded that although light microscopy and immunofluorescence findings could indicate diabetic nephropathy, the electron microscopy lesions suggest the diagnosis of PIG. Conclusion To our knowledge, this is the first reported case with PIG and anti-PLA2R antibodies detected in the serum, without clear histological evidence of membranous nephropathy. Our patient was diabetic for five years with no diabetic lesions in fundoscopy. Although PIG has been reported mainly in the context of autoimmune diseases, the coexistence with diabetes or its possible role in PIG's pathogenesis has not been addressed. The treatment of this peculiar morphologically disease, still remains an open query for physicians.

Abstract #1412835: A Case of Cowden Syndrome

Cowden syndrome is part of the PTEN Hamartoma Tumor Syndrome spectrum. It is characterized by the presence of multiple hamartomas on the skin and mucous membranes and an increased risk of developing cancers of the thyroid, breast, uterus, kidney, colon, rectum and skin. Most cases are caused by genetic changes in the phosphatase and tensin homolog (PTEN) gene, inherited in an autosomal dominant manner. It is rare with an estimated prevalence of 1 in 200,000 to 250,000. A 36-year-old female presented to the Veteran Affairs Endocrinology clinic for follow up of thyroid cancer. She had undergone a total thyroidectomy 9 years prior due to a large goiter, with pathology revealing papillary thyroid cancer. She received radioactive iodine ablation afterwards. Thyroid ultrasound showed a heterogenous soft tissue density measuring 1.8 x 1.1 x 1.6 cm in the left thyroid bed. Fine needle biopsy of the mass confirmed recurrent papillary thyroid cancer. Her medical history includes endometriosis with right ovary cyst for which she underwent total hysterectomy with bilateral salpingo-oophorectomy, benign colon polyps status post resection, gallbladder polyps status post cholecystectomy, bilateral breast masses (measuring 0.5 cm on the right and 0.8 cm on the left) and multiple skin lesions. Family history is significant for multiple benign skin lesions and colon polyps in her father and breast cancer and endometriosis in her paternal aunts. Due to her extensive personal and family history of tumors, a comprehensive hereditary cancer panel was sent out. Results came back positive for the PTEN gene, indicating a diagnosis of Cowden syndrome. She was referred to oncology for cancer surveillance, dermatology for regular skin checks and surgery for prophylactic mastectomy. She does not plan to have children, and she was advised to notify her first-degree family to have genetic testing done. Patients with Cowden syndrome may present to the Endocrinology clinic for management of non-medullary thyroid cancer, multinodular goiter or Hashimoto’s thyroiditis and may be noted to have multiple skin and mucous membrane lesions. They may report a history of breast tumors, endometrial abnormalities and polyps as in this case. After diagnosis is confirmed by genetic testing, cancer surveillance is the major focus of medical management given the high risk of malignancy.

Evaluation of IR and Raman spectroscopic markers of human collagens: Insides for indicating colorectal carcinogenesis

Vibrational spectroscopic methods are widely used in the molecular diagnostics of carcinogenesis. Collagen, a component of connective tissue, plays a special role as a biochemical marker of pathological changes in tissues. The vibrational bands of collagens are very promising to distinguish between normal colon tissue, benign and malignant colon polyps. Differences in these bands indicate changes in the amount, structure, conformation and the ratio between the individual structural forms (subtypes) of this protein. The screening of specific collagen markers of colorectal carcinogenesis was carried out based on the FTIR and Raman (λex 785 nm) spectra of colon tissue samples and purified human collagens. It was found that individual types of human collagens showed significant differences in their vibrational spectra, and specific spectral markers were found for them. These collagen bands were assigned to specific vibrations in the polypeptide backbone, amino acid side chains and carbohydrate moieties. The corresponding spectral regions for colon tissues and colon polyps were investigated for the contribution of collagen vibrations. Mentioned spectral differences in collagen spectroscopic markers could be of interest for early ex vivo diagnosis of colorectal carcinoma if combine vibrational spectroscopy and colonoscopy.

Polyp Size and Shape Estimation by Using an Endoscopic Hood Information

Medical doctors identify benign or malignant colon polyps by their size and shape. Since this identification is related to whether or not resection surgery is necessary, a technology for estimating absolute size and shape from endoscopic images is required. In previous research, the method for recovering the size and shape of polyps using a blood vessel region as a reference object has been proposed. This paper proposes a method to recover the size and shape of polyps by using a cylindrical endoscopic hood as a reference object. The experimental results confirm that the proposed method can estimate reflectance factor without using blood vessel information.

S2184 A Case of Colonic Perforation After CT Colonography

Introduction: CT colonography is increasingly used in patients with failed initial colonoscopy. Although it is relatively considered a safe procedure but can have serious rare complications with significant morbidity and mortality. We present a case of a patient with failed colonoscopy due to severe diverticular disease who was referred for a CT colonography. Case Description/Methods: 70 years old male with the history of hypertension, dyslipidemia and recurrent diverticulitis who underwent colonoscopy for diagnostic purposes after recent episode of diverticulitis 3 months ago. Patient last colonoscopy 5 years ago showed extensive diverticular disease and one benign colonic polyp. Colonoscopy was attempted however despite using pediatric colonoscope we were not able to pass the sigmoid colon because of severe angulation and luminal narrowing. After discussion with the patient, decision was made to refer for CT colonography which was performed 2 months later which showed severe sigmoid diverticulosis. Note that the colon was insufflated with carbon dioxide gas.One day after the procedure, patient presented to the outside hospital with worsening abdominal pain and was found to have sigmoid perforation & air under diaphragm (Figure). He was taken to the OR urgently and underwent sigmoid resection with creation of colostomy with reversal later. Pathology was negative for malignancy but showed diverticulosis, diverticulitis and serosal adhesions. Discussion: CRC is the third most common cause of cancer and second leading cause of death from cancer. There are range of screening tests available for CRC screening including stool test, colonoscopy and radiological test including CT colonography. Although CT colonography is relatively a benign procedure but occasionally can cause serious complications. A retrospective analysis by Burling et al. found incidence of colonic perforation 0.08% after analysis of 17067 colonography examinations, while symptomatic perforation rate was 0.03%. (1) The data on colonic perforation after CTC is low (0.005%-0.03%) compared to colonoscopy (0.06%-0.19%) (2). Although CTC is a safe procedure we suggest that prior to referral for this procedure, a detailed risks benefits discussion should be held between the patient and physician.Figure 1.: Left: Sigmoid colon perforation. Right: Free air under diaphram.

Accuracy and Inter-observer Agreement Among Endoscopists for Visual Identification of Colorectal Polyps Using Endoscopy Images.

It is essential to accurately distinguish small benign hyperplastic colon polyps (HP) from sessile serrated lesions (SSL) or adenomatous polyps (TA) based on endoscopic appearances. Our objective was to determine the accuracy and inter-observer agreements for the endoscopic diagnosis of small polyps. High-quality endoscopic images of 30 small HPs, SSLs, and TAs were used randomly to create two-timed PowerPoint slide sets-one with and another one without information on polyp size and location. Seven endoscopists viewed the slides on two separate occasions 90days apart, identified the polyp type, and graded their confidence level. Overall and polyp-specific accuracies were assessed for the group and individual endoscopists. Chi-square tests and Kappa (κ) statistics were used to compare differences as appropriate. When polyp size and location were provided, overall accuracy was 67.1% for TAs, 50.0% for SSLs, and 41.4% for HPs; the corresponding accuracies were 60%, 44.3%, and 34.3% when polyp size and location were withheld (p < .001). Inter-observer agreement was moderate for TAs (κ = 0.50) and fair for SSLs (κ = 0.26) and HPs (κ = 0.29); the corresponding inter-observer agreements were 0.44, 0.31, and 0.17 with polyp size and location withheld. Accuracy was not affected by knowledge of polyp size, location, or confidence level. Endoscopists with ≥ 10years (vs. < 10years) of colonoscopy experience had marginally higher (56% vs. 40%, p = 0.05) accuracy for SSL diagnosis. The ability to distinguish between small TAs, SSLs, and HPs on their endoscopic appearance is poor regardless of the endoscopists' knowledge of polyp size and location.

Combined endoscopic and laparoscopic surgery for the treatment of complex benign colonic polyps (CELS): Observational study

PurposeCombined endoscopic and laparoscopic surgery (CELS) has emerged as a promising method for managing complex benign lesions that would otherwise require major colonic resection. The aim of this study was to describe the different techniques and to evaluate the safety of CELS, assess its outcomes in a technique that is scarcely widespread in our environment. MethodObservational retrospective study, short-term outcomes of patients undergoing CELS for benign colon polyps from October 2018 to June 2020 were evaluated. Postoperative outcomes, length of hospital stay and pathological findings were evaluated. ResultsSeventeen consecutive patients underwent CELS during the study period. The median size of the lesion was 3.5 cm (range 2.5–6.5 cm), the most frequent location was the cecum (10 from 17). Most patients treated with CELS underwent an endoscopic-assisted laparoscopic wedge resection (11 from 17). In four patients this resection was combined with another CELS technique, and two patients underwent an endoscopic-assisted laparoscopic segment resection. The success rate of CELS in our series was in 14 from 17 (82.4%). The median operative time was 85 min (range 50−225 min). The median hospital stay was 2 days (range 1–15 days). One patient experienced an organ/space surgical site infection which did not require further intervention. Four lesions were shown to be malignant by postoperative pathology study. ConclusionCELS is a safe and multidisciplinar technique that requires collaboration between gastroenterologists and surgeons. It can be considered as an alternative to colonic resection for complex benign colonic polyps.

Colectomy for polyps is associated with high risk for complications and low risk for malignancy: Time for endoluminal surgery?

DR. FREDERICK LANE (Indianapolis, Indiana): I'd like to thank the authors for the opportunity to review this paper which seeks to make the case for aggressive endoscopic management of benign colon polyps. Having worked with NSQIP in the past, I realized some items are difficult to extract from the data set, and you addressed this a little bit. You report an upstage rate to cancer of 3.3% in surgeries for colon polyps. How comfortable are you with this number, as I wonder how many of those potentially upstaged patients were listed as cancer patients rather than for coding purposes and, therefore, not really included?

Management of the colonic polyps referred for surgery: an opportunity for improvement.

To examine local practice for non-malignant polyps and to calculate morbidity and mortality associated with bowel resection for this indication. This retrospective cohort study was conducted by reviewing our local gastrointestinal pathology database over a five-year period to identify colonic resections performed for benign polyps. Using search terms "polyp" and "adenoma," 272 cases were identified. Exclusion criteria included: cancer diagnosis, emergency surgeries, multiple resections, and subtotal colectomies for polyposis. 106 patients were included in the study. Primary outcome was perioperative mortality. Secondary outcomes included patient morbidity, characteristics of polyps requiring surgery, and the numberof patients referred for asecond endoscopic opinion prior toproceeding with surgery. 64 male and 42 female patients with a mean age of 65.3years (± 8.6years) underwent colon resection for benign polyps. The mean polyp size was 32.7mm (± 19.5mm). 30 patients (28.6%) had polyps equal to or less than 2cm. Most of the polyps described were sessile (n = 55, 51.9%) and located in the right colon (n = 84, 79.3%). Endoscopic resection was attempted in 31 patients (29.2%), and five cases (4.7%) were referred for a second endoscopic opinion prior to proceeding with surgery. Endoscopists incorrectly felt that polyps were malignant in 62 cases (58.5%). Using Clavien-Dindo classification, most patients had no complications n = 36 (34.0%) or minor complications n = 41 (38.7%). Twelve patients (11.3%) had complications that required antibiotics, blood transfusions, or total parental nutrition. Nine patients (8.5%) required surgical or endoscopic management. Six patients (5.7%) required ICU admission. Mortality rate was 1.9% (n = 2). Surgery for benign colonic polyps is associated with significant morbidity and mortality. These findings reveal a gap in endoscopic management of benign colonic polyps.

Full-Thickness Laparoendoscopic Excision for Management of Complex Colon Polyps.

Benign colon polyps are increasingly being detected because of improved colonoscopic screening and early detection of masses on the adenoma-to-carcinoma pathway. Full-thickness laparoendoscopic excision is a colon-preserving technique for endoscopically unresectable polyps consisting of endoscopically guided nonanatomic wedge colectomy. This study aimed to evaluate the safety and success of full-thickness laparoendoscopic excision compared to segmental colectomy for complex polyps not amenable to endoscopic resection. This is a retrospective case-control study. This study was conducted at a tertiary academic center. A prospectively maintained institutional database identified 22 patients with benign complex polyps managed with full-thickness laparoendoscopic excision from 2015 to 2020. These patients were compared with 22 propensity score-matched controls from the same database that underwent laparoscopic segmental colectomy. Primary outcome was inpatient length of stay. Secondary outcomes included operative details and postoperative morbidities. Full-thickness laparoendoscopic excision was successful in all patients. Patients had a median age of 64 years (41-85), and 82% were men. Final pathology revealed complete excision of benign lesions in 20 of 22 patients and adenocarcinoma in 2 of 22. For the adenocarcinomas, 1 patient underwent subsequent elective colectomy without complications, and 1 patient declined surgery. Propensity score matching was successful for age, sex, BMI, ASA score, colon location, and prior abdominal surgery. Compared with controls, cases had significantly shorter operative time (89.5 minutes (46-290) vs 122 minutes (85-200), p = 0.009), length of stay (1 day (0-17) vs 3 days (1-8), p < 0.001), and reduced blood loss (5 mL (2-15) vs 25 mL (10-150), p < 0.001). Thirty-day morbidity (9.1% vs 27.3%, p = 0.240) was not significantly different. An unplanned 30-day reoperation was performed in 1 patient for suspected small-bowel obstruction. There was 1 mortality due to decompensated cirrhosis in the treatment group. This study was limited by its single-institution retrospective design. Full-thickness laparoendoscopic excision is safe and successful compared with corresponding segmental colectomy for complex polyps. Favorable postoperative outcomes, including decreased operative time, length of stay, and blood loss, make it a useful approach for managing complex polyps throughout the colon.

Ex Vivo Vibration Spectroscopic Analysis of Colorectal Polyps for the Early Diagnosis of Colorectal Carcinoma.

Colorectal cancer is one of the most common and often fatal cancers in humans, but it has the highest chance of a cure if detected at an early precancerous stage. Carcinogenesis in the colon begins as an uncontrolled growth forming polyps. Some of these polyps can finally be converted to colon cancer. Early diagnosis of adenomatous polyps is the main approach for screening and preventing colorectal cancer, and vibration spectroscopy can be used for this purpose. This work is focused on evaluating FTIR and Raman spectroscopy as a tool in the ex vivo analysis of colorectal polyps, which could be important for the early diagnosis of colorectal carcinoma. Multivariate analyses (PCA and LDA) were used to assist the spectroscopic discrimination of normal colon tissue, as well as benign and malignant colon polyps. The spectra demonstrated evident differences in the characteristic bands of the main tissue constituents, i.e., proteins, nucleic acids, lipids, polysaccharides, etc. Suitable models for discriminating the three mentioned diagnostic groups were proposed based on multivariate analyses of the spectroscopic data. LDA classification was especially successful in the case of a combined set of 55 variables from the FTIR, FT Raman and dispersion Raman spectra. This model can be proposed for ex vivo colorectal cancer diagnostics in combination with the colonoscopic extraction of colon polyps for further testing. This pilot study is a precursor for the further evaluation of the diagnostic potential for the simultaneous in vivo application of colonoscopic Raman probes.

TP7.2.20 Systematic Review and meta-analysis of Interventions for Benign Large Non-Pedunculated Colonic Polyps (BLNPCP)

Abstract Aim To examine the efficacy of treatment options for benign large non-pedunculated colonic polyps (BLNPCP). Background BLNPCP may harbour covert malignancy and opinions differ about the optimal treatment modality, be it endoscopic mucosal resection (EMR), endoscopic submucosal resection (ESD), combined endoscopic laparoscopic surgery (CELS) or surgical resection (SR). Despite the widespread availability of endoscopic resection (ER) techniques, rates of surgery in the UK remain high. Methods This review is reported in line with PRISMA guidelines (PROSPERO registration: CRD42021148944). EMBASE, CENTRAL, and MEDLINE databases were searched from January 2000 to January 2020 to evaluate interventions for treating BLNPCP in adults. The primary outcome was recurrence, adverse events were secondary outcomes. Meta-analysis was performed using a random effects model expressed as a percentage with 95% confidence interval. Quality assessment was performed using ROBINS-I. Results Ten studies (2499 polyps in 2327patients) were included (five assessed EMR, four SR, two CELS, two ESD). All studies were at moderate risk of bias. SR, ESD and CELS had the lowest recurrence rates 0% CI:0-1, 1% CI:0-2 and 2% CI:0-12 respectively. EMR had the highest (15% CI:9-22). SR complication rate was 12% CI:7-19, ESD 12% CI:9-15, CELS and EMR 11% CI:0-45 and 7% CI:5-9 respectively. Rescue surgery for complication or finding of invasive cancer was 17% CI:5-35 for ESD, CELS 14% CI:3-30, EMR 11% CI:7-15, SR 4% CI:2-6. Conclusion These data provide information that should be taken into account when considering the choice of intervention. It will allow a more robust shared decision-making process to occur.

EP.TH.602Exploring decision-making of healthcare professionals in patients with benign large non-pedunculated colonic polyps (BLNPCP) virtually using combined focus group and nominal group technique

Abstract Aim We aimed to elicit key factors that influence healthcare professional decision-making when deciding treatment for BLNPCP. Background Benign large non-pedunculated colonic polyps (BLNPCP) may harbour covert malignancy and opinions differ about the optimal treatment modality. There are several options available, including endoscopic mucosal resection, endoscopic submucosal resection, combined endoscopic laparoscopic surgery and surgical resection. Despite widespread availability of endoscopic resection techniques, there are high rates of surgery in the UK. Methods Three focus groups of healthcare professionals, comprised of either consultant colorectal surgeons, nurse endoscopists and consultant gastroenterologists, were conducted virtually utilising the Nominal Group Technique. Meetings were recorded and transcribed verbatim. Themes were devolved using the framework approach for qualitative analysis. A priority-ranked list of factors influencing healthcare professional decision-making in this setting was generated. Results Five main themes were identified as influencing decision-making: Shared decision making (patient preference, informed consent); Patient factors (co-morbidity, age, life-expectancy); Polyp factors (Location, size, morphology, risk of cancer); Healthcare professionals (skill-set, personal preference); System factors (techniques availability locally, regional referral networks). Nominal Group Technique generated 55 items across the three focus groups. Nurses and gastroentologists ranked patient factors (particularly drug history and tolerance of procedure) and shared decision making (patient preference) more highly then surgeons. Surgeons placed greater emphasis on polyp factors particularly location and the risk of submucosal invasive carcinoma. Conclusion Decision making is complex and multifactorial. These results support the benefits of complex polyp MDTs and patient involvement in the decision-making. The complexity of decision-making may underpin wide variation in practice.

Impact of the COVID-19 Pandemic on Primary Health Care Disease Incidence Rates: 2017 to 2020.

We assessed the impact of the COVID-19 pandemic in Spain on new cases of diseases and conditions commonly seen in primary care. In 2020, there were significant reductions from 2017-2019 in the annual incidences of hypertension (40% reduction), hypercholesterolemia (36%), type 2 diabetes (39%), chronic kidney disease (43%), ischemic heart disease (48%), benign prostatic hypertrophy (38%), osteoporosis (40%), hypothyroidism (46%), chronic obstructive pulmonary disease (50%), alcohol use disorder (46%), benign colon polyps and tumors (42%), and melanomas (45%). Prioritization of COVID-19 care changed the physician-patient relationship to the detriment of face-to-face scheduled visits for chronic disease detection and monitoring, which fell by almost 41%. To return to prepandemic levels of diagnosis and management of chronic diseases, primary health care services should reorganize and carry out specific actions for groups at higher risk.VISUAL ABSTRACTAnnals "Online First" article.

ID: 3524655 REFERRAL PATTERNS FOR ENDOSCOPIC RESECTION OF LARGE COLON POLYPS AMONG ACADEMIC VS. COMMUNITY-BASED GASTROENTEROLOGISTS: A SINGLE ACADEMIC TERTIARY CARE CENTER EXPERIENCE

Endoscopic mucosal resection (EMR) is a safe and cost-effective method of removing large, benign colon polyps with a low risk of complications and high rates of clinical success. As rates of colon polyps being referred for EMR continue to rise, it is important to recognize and understand trends in referral patterns for colon polyp EMR.

Cirugía endoscópica y laparoscópica combinada para el tratamiento de pólipos de colon benignos complejos (CELS): estudio observacional

PurposeCombined endoscopic and laparoscopic surgery (CELS) has emerged as a promising method for managing complex benign lesions that would otherwise require major colonic resection. The aim of this study was to describe the different techniques and to evaluate the safety of CELS, assess its outcomes in a technique that is scarcely widespread in our environment. MethodObservational retrospective study, short-term outcomes of patients undergoing CELS for benign colon polyps from October 2018 to June 2020 were evaluated. Postoperative outcomes, length of hospital stay and pathological findings were evaluated. ResultsSeventeen consecutive patients underwent CELS during the study period. The median size of the lesion was 3.5 cm (range 2.5 – 6.5 cm), the most frequent location was the cecum (10 from 17). Most patients treated with CELS underwent an endoscopic-assisted laparoscopic wedge resection (11 from 17). In four patients this resection was combined with another CELS technique, and two patients underwent an endoscopic-assisted laparoscopic segment resection. The success rate of CELS in our series was in 14 from 17 (82,4%). The median operative time was 85 min (range 50-225 min). The median hospital stay was 2 days (range 1-15 days). One patient experienced an organ/space surgical site infection which did not require further intervention. Four lesions were shown to be malignant by postoperative pathology study. ConclusionCELS is a safe and multidisciplinar technique that requires collaboration between gastroenterologists and surgeons. It can be considered as an alternative to colonic resection for complex benign colonic polyps.

Combined endoscopic-laparoscopic surgery (CELS) can avoid segmental colectomy in endoscopically unremovable colonic polyps: a cohort study over 10 years.

Combined-Endoscopic-Laparoscopic-Surgery (CELS) was developed for benign colonic polyps, endoscopically unresectable, to avoid segmental colectomy. This observational study aims to compare surgical outcomes of endoscopically unresectable colonic polyps treated laparoscopically before and since the institutional introduction of CELS. Primary endpoint was postoperative morbidity and mortality; secondary endpoints were time of hospitalization and histopathological findings. Charts of all patients with preoperative diagnosis of benign colonic tumors, treated laparoscopically at our institution from 1/2010 to 2/2020 were reviewed. Patients with polyps (1) affecting ileocecal valve, (2) occupying > 50% of the circumference, (3) ≥ 3 endoscopically unresectable polyps, (4) inflammatory bowel disease, (5) polyps within diverticular area post diverticulitis, (6) rectal polyps (7) foreseen impossibility of laparoscopy (8) preoperatively biopsy proven invasive adenocarcinoma were excluded. Group I consists of all patients potentially treatable by CELS but operated by laparoscopic colonic resection as CELS was not yet institutionally established. Group II includes all patients treated with CELS (since 11/2017). One hundred-fifteen consecutive patients were reviewed. Applying exclusion criteria, twenty-three patients form group I and twenty-three group II (female 30.4%, median age 68 years). Groups distributed homogenously for age, BMI (body mass index) and polyps´ localization with most polyps (60.4%) localized in right colon; group II patients had significantly higher American Society of Anesthesiologists (ASA) score. Median operating time, hospital stay and morbidity were significantly less in group II. Postoperative morbidity occurred overall in 14 patients (30.4%), mostly Clavien-Dindo class I-II (26.1%) and significantly less in group II (p = 0.017), Clavien-Dindo III-IV distributed equally (one patient each group) without postoperative mortality. Definitive histopathology showed invasive adenocarcinoma in 8.3% without differences between groups. Two patients with invasive adenocarcinoma after CELS were advised for oncological resection. CELS is safe and efficient to treat complex, benign colonic polyps by a complete minimal invasive laparoscopic approach. CELS showed better surgical outcomes with less morbidity, no mortality and appropriate pathological results avoiding unnecessary laparoscopic surgery with intestinal anastomosis.