Benign Sessile Research Articles

Distinct Wnt Signaling Thresholds Required for Polyposis in the Proximal and Distal Stomach

ObjectiveThe Wnt pathway is critical for gastrointestinal stem cell proliferation. Patients with Familial Adenomatous Polyposis (FAP) have germline mutations in the adenomatous polyposis coli (APC)gene, resulting in dysregulated Wnt signaling and a polyposis syndrome with stark regional differences in disease severity. In the stomach, the proximal corpus contains numerous polyps, while few polyps are located in the distal antrum. Here, we tested the hypothesis that there are regional differences in sensitivity to Wnt signaling along the gastric proximal‐distal axis, and that a ‘just‐right’ level of Wnt signaling is required for gastric polyposis.MethodsTo model gastric polyp formation in FAP patients, we used mice with an inducible Apcloss‐of‐function mutation. Gastric tissue responses were studied one month after maximal Wnt activation in homozygous Sox2‐CreERT2; Apc580flox/flox(APC‐/‐) and submaximal Wnt activation in heterozygous Sox2‐CreERT2; Apc580flox/+ (APC+/‐) mice. To gain insight into regional differences in Wnt response, RNA sequencing was performed on corpus and antral organoids treated with the Wnt inhibitor XAV939.ResultsIn the distal stomach, we observed hyperproliferation and tissue expansion in homozygous APC‐/‐ mice with no change in heterozygous APC+/‐mice. In contrast, the proximal stomach did not show an effect in homozygous APC‐/‐ mice but showed a modest increase in proliferation in heterozygous mice. PCR analysis of APC‐/‐ tissue confirmed APC gene deletion in the antrum, but not corpus, suggesting regional differences in maintenance of homozygous mutant stem cells. Following acute Wnt inhibition, corpus and antral organoids shared many Wnt‐regulated genes. However, Gene Ontology Enrichment analysis showed genes associated with cell differentiation, cell population proliferation, and cell cycle regulation were upregulated in antral organoids but downregulated in corpus organoids. KEGG analysis indicated downregulation of gastric cancer genes in both tissue organoids; however, only antral organoids showed downregulation of signaling pathways regulating pluripotency.ConclusionThe corpus and antrum exhibit differences in the Wnt signaling threshold required to initiate polyposis. Whereas submaximal levels of Wnt signaling are sufficient to initiate growth in the corpus, maximal levels are needed for antral hyperproliferation. Notably, ‘high‐Wnt’ stem cells are retained in the antrum and lost from the corpus, suggesting regional differences in Wnt regulation of gastric stem cells. Our findings in mouse highlight how heterozygous APC mutations may be sufficient for proximal stomach polyposis—a clinically relevant observation, as the vast majority of FAP patient gastric polyps are benign sessile growths located in the proximal stomach, with less frequent antral adenomatous polyps more closely associated with gastric cancer.

Endoscopic Treatment of Sessile Colorectal Polyp

Background: Endoscopic resection of sessile colonic polyps’ presents a number of unique challenges. Large sessile polyps are associated with the greatest risk of postpolypectomy bleeding, perforation and polyp recurrence, with massive submucosal scarring making subsequent attempts at endoscopic resection problematic. Objective: This study aimed to evaluate feasibility, safety, and the effectiveness of endoscopic treatment of colorectal benign-appearing polyps. Patients and methods: This prospective study was carried out on forty (40) consecutive patients at General Surgery Department, Al-Azhar University Hospitals, Cairo, Egypt between January 2014 and August 2016. All patients were subjected to clinical evaluation including history taking, general examination, abdominal and per-rectal examinations. Results: Of the 40 cases with removed polyps, 10 cases were excised by cold biopsy forceps, 4 cases were excised by cold snare, 12 cases were excised by hot snare and 14 cases were excised by EMR with mucosal lifting according to the size of the polyp. Complications included nonspecific abdominal pain in 5 patients (12.5%) that were treated conservatively and bleeding in 3 (7.5%), two cases during procedure while 1 case presented 7 th day post procedure. One case transferred into open surgery due to perforation. All cases were treated endoscopically. Post-polypectomy surveillance permitted the detection and treatment of recurrent polyps in 3 cases that treated endoscopically with piece meal excision. Conclusion: This study showed that polypectomy of benign sessile colorectal polyps performed by an expert endoscopist is feasible, effective, and safe, even on an outpatient basis.

1584 A Rare Case of Follicular Lymphoma of Sigmoid Colon

INTRODUCTION: Follicular lymphoma is defined as a neoplasm of follicle B cells and is characterized immunohistochemically by a positive reaction to B-cell markers and Bcl-2. Follicular lymphomas of the colon are very rare. Within GI Lymphomas, colorectal lymphomas are very uncommon and account for only 3% of GI lymphomas and 0.3% of large intestinal malignancies. We describe an unusual presentation of extra-nodal follicular lymphoma within the sigmoid colon. CASE DESCRIPTION/METHODS: A 59-year-old Caucasian female with history of hypertension was referred by her primary care physician for an average risk screening colonoscopy. Prior to referral for screening colonoscopy, the patient was being screened for colon cancer with annual occult stool testing which had been negative. She underwent a colonoscopy which showed a sessile polyp in the hepatic flexure and two polypoid lesions in the sigmoid colon (Figure 1). The patient was referred for endoscopic mucosal resection of the polyps. A snare mucosal resection was performed for the hepatic flexure polyp (12 mm in size). The 2 sessile polyps in the sigmoid colon (8-12 mm in size) were also resected with a hot snare. Pathology from the sigmoid colon polyp was consistent with Grade IIIA Follicular Lymphoma and immunohistochemistry was positive for CD20, CD10, BCL6 and BCL2 (Figure 2). The polyp in the hepatic flexure was noted to be a benign sessile serrated polyp. Patient was referred to Oncology for further management. A bone marrow biopsy and PET/CT did not show any evidence of disease involvement elsewhere. DISCUSSION: Primary NHLs of the GI tract are rare, accounting for only 1 to 4 percent of malignancies arising in the stomach, small intestine, or colon. Colonoscopy with biopsy is the principal diagnostic modality. Colonoscopic findings of follicular lymphomas include mucosal ulcerations, diffuse mucosal nodularity or polypoid mass like lesions. However, due to its rarity, an optimal diagnostic work up and treatment plan has not been well established. Making a correct diagnosis of the disease based on findings of biopsied samples can be challenging and multiple biopsies or endoscopic mucosal resection may be required in addition to appropriate consultation with pathologists.

Endoscopic Treatment of Sessile Colorectal Polyp

Background: Endoscopic resection of sessile colonic polyps’ presents a number of unique challenges. Large sessile polyps are associated with the greatest risk of postpolypectomy bleeding, perforation and polyp recurrence, with massive submucosal scarring making subsequent attempts at endoscopic resection problematic. Objective: This study aimed to evaluate feasibility, safety, and the effectiveness of endoscopic treatment of colorectal benign-appearing polyps. Patients and methods: This prospective study was carried out on forty (40) consecutive patients at General Surgery Department, Al-Azhar University Hospitals, Cairo, Egypt between January 2014 and August 2016. All patients were subjected to clinical evaluation including history taking, general examination, abdominal and per-rectal examinations. Results: Of the 40 cases with removed polyps, 10 cases were excised by cold biopsy forceps, 4 cases were excised by cold snare, 12 cases were excised by hot snare and 14 cases were excised by EMR with mucosal lifting according to the size of the polyp. Complications included nonspecific abdominal pain in 5 patients (12.5%) that were treated conservatively and bleeding in 3 (7.5%), two cases during procedure while 1 case presented 7 th day post procedure. One case transferred into open surgery due to perforation. All cases were treated endoscopically. Post-polypectomy surveillance permitted the detection and treatment of recurrent polyps in 3 cases that treated endoscopically with piece meal excision. Conclusion: This study showed that polypectomy of benign sessile colorectal polyps performed by an expert endoscopist is feasible, effective, and safe, even on an outpatient basis.

Treatment of Pyogenic Granuloma using Er,Cr:YSGG Laser

Pyogenic granuloma (PG) is a common, usually solitary, benign sessile or pedunculated vascular proliferation of the skin and mucous membranes, presenting as hemorrhagic growth, especially in children and women of reproductive age. The lesion is unrelated to infection and arises in response to various stimuli, such as low grade local irritation, traumatic injury or hormonal factors. This report presents a case of a 47 years old male with a PG in relation to lower anteriors. This lesion was removed using an Er,Cr:YSGG laser. The healing was uneventful and no suture or analgesic was required.

Current practice and feasibility in microlaryngeal surgery: microsurgical pressing excision technique

Since the introduction of endolaryngeal microsurgery, several basic microsurgical techniques have been described for the removal of benign vocal fold lesions. These techniques include conventional incision or dissection, bimanual retraction and cutting, microflap technique and the CO2 laser. Until recently, only a few microsurgical methods have emerged as new choices for the treatment of benign vocal fold lesions. This article introduces an innovative method that can precisely remove benign sessile vocal fold lesions with epithelial keratosis or hyperplasia without jeopardizing the intermediate or deep layer of the lamina propria. Instead of using conventional vertically opening microinstruments, this microsurgical pressing excision technique (MPET) utilized two pairs of custom-made horizontally left-opening or right-opening, curved microscissors/curved cupped microforceps to remove right or left vocal fold lesions accordingly. Using one instrument at a time, the lesion was subsequently removed with the microscissors and microforceps in a press-evert-cut manner. Among a total of 553 cases, the treatment results were satisfactory, with 520 (94%) patients retaining a satisfactory/normal (G0) voice 2 months postoperatively. More importantly, no patient's voice was worse postoperatively. This technique has several advantages: utilizing one instrument at a time can maximize exposure of the narrow endoscopic view, adjusting the pressing force makes precise excision easy in a well controlled horizontal plane. The MPET is particularly useful for removing sessile vocal nodules (especially those with epithelial keratosis), epithelial hyperplasia and leukoplakia in patients with difficult endolaryngeal exposure. This could be a well tolerated and precise microsurgical technique.

Local Full-Thickness Excision as First Line Treatment for Sessile Rectal Adenomas

Removing rectal adenomas not only relieves symptoms, but also eradicates the incidence of carcinoma. There are many techniques for local removal of rectal polyps. Transanal endoscopic microsurgery (TEM) is the most recent. The purpose of this study is to present our long-term results using TEM for rectal adenomas, paying special attention to the risk factors of harboring a malignancy. Data from all patients undergoing TEM from December 1995 to December 2005 were collected prospectively. The selection criteria were benign sessile adenomas below the peritoneal reflection. In the study period, 173 patients were operated on for an apparently benign rectal adenoma. The mean distance of lower tumor was 7.6 cm (range, 1-18 cm), and the mean distance to upper edge was 11 cm (2-20 cm). Full-thickness local excision was performed in all procedures. Patients were followed for a minimum of 1 year. According to the histologic findings, 14% of the specimens were invasive carcinomas. No statistical differences were found when comparing the histologic findings by tumor size, distance to the anal verge, or location.In 10 (5.8%) cases, the dissection was considered uncompleted because of a normal mucosa margin smaller than 1 mm. The mean hospital stay was 4 days (2-30 days). The morbidity rate was 14.5%. There was 1 postoperative death (0.6%). There were 9 (5.4%) histologically proven recurrences. Four of the patients with recurrence had uncompleted microscopic circumferential resection (P = 0.001). At a mean follow-up of 35 months (range, 12-82 months), all carcinoma patients were alive with no evidence of disease. In conclusion, a significant number of adenomas that we assumed preoperatively to be benign were already carcinomas and we were unable to find any reliable predictor to identify them. TEM full-thickness excision provided a low rate of postoperative morbidity and potentially avoided a significant number of major abdominal operations and local recurrences.

Laparoscopic colonoscopic rendezvous procedures for the treatment of polyps and early stage carcinomas of the colon

Endoscopic treatment of large or colonoscopically inaccessible polyps or early stage tumors in the colon holds the risk of incomplete resection and colonic perforation. The combination of colonoscopy and laparoscopy offers a minimally invasive treatment modality for the complete resection of polyps with low risk. Aim of this study was to assess the feasibility and outcome of patients operated on by laparoendoscopic rendezvous procedures at the colon. The medical records of 38 patients (21 male, 17 female, median age 66 years [range 39-90]) undergoing rendezvous surgery at the colon were reviewed prospectively. Follow-up data were obtained by clinical examination and personal communication via telephone or questionnaire. The median follow up was 54 months. From January 1998 until April 2007, 38 patients were treated with rendezvous procedures in our hospital. In 30 cases, a colonoscopically assisted laparoscopic procedure was performed and in eight patients a laparoscopically controlled colonoscopic procedure. A benign lesion was confirmed histologically in 31 patients. In five cases, histopathologic diagnosis revealed a malignancy necessitating colonic surgery. A coprolith extraction and a suture of the sigma were performed in one case each. Complications occurred in two patients. One patient developed an anastomosis insufficiency that necessitated a revision. One patient developed pneumonia postoperatively. A conversion to laparotomy had to be performed in two cases. Rendezvous procedures offer a safe, minimal-invasive therapeutic approach allowing the resection of benign sessile or colonoscopically inaccessible localized polyps and of early stage colon cancer.

Chronic Knee Pain in a 21-Year-Old Woman

Chronic Knee Pain in a 21-Year-Old Woman

SESSILE ADENOMAS OF THE RECTUM: A PERSONAL SERIES 1974‐1984

Sessile (villous) tumours of the rectum are uncommon and individual surgeons are unlikely to have wide experience in their management. A study was made of a unique personal series (AMC) of 104 cases encountered from 1974 to 1984; minimum duration of follow-up was 5 years. Clinically obvious rectal cancers were excluded from the study. Ages ranged from 42 to 89 years (mean 64.9 years) with a male:female ratio of 1.5:1. The commonest clinical presentations of sessile tumours of the rectum were rectal bleeding (45%) and altered bowel habit (38%). Hypokalaemia was a very uncommon presenting symptom (1%). These tumours ranged in longitudinal diameter from 1 to 9 cm, with 66% of cases greater than 3 cm and 33% of cases greater than 5 cm. The incidence of malignancy in sessile adenomas greater than 3 cm (27%) was more than triple that of adenomas less than 3 cm (8%) and the presence of induration on rectal examination was the most reliable clinical indicator of the presence of malignancy. Local transanal diathermy excision was a satisfactory form of treatment for most sessile tumours of the rectum (benign and malignant); especially if they were less than 3 cm (0% recurrence rate). It had the added advantage of preserving the anal sphincter and was possible in a higher proportion of sessile tumours in the lower half of the rectum (89%) than those in the upper half of the rectum (42%). The overall recurrence rate after local transanal excision was 8% for benign sessile adenomas and 33% for those containing invasive carcinoma.(ABSTRACT TRUNCATED AT 250 WORDS)

Laser therapy in the management of benign and malignant tumours in the colon and rectum.

Since 1983 the Neodymium-YAG laser has been used endoscopically to treat 93 patients with inoperable colorectal carcinoma and 18 patients with benign sessile adenomas. In an additional 11 patients with colorectal cancer, photodynamic therapy (PDT) has been applied using an argon-pumped dye laser. Objective and subjective measurements of quality of life have shown the beneficial effects of the Nd-YAG laser in the relief of symptoms, and four patients have apparently been rendered disease free. Benign tumours also respond to Nd-YAG ablation but close histological supervision is necessary to detect malignant transformation at an early stage. Although PDT may offer a potential for cure in small inoperable tumours, it seems likely that Nd-YAG laser treatment will remain the laser option of choice for advanced bulky tumours.

Technique of Colonoscopic Polypectomy

Most colonic polyps can be removed colonoscopically from all reaches of the colon, provided that one is experienced with endoscopic morphology and snare electrosurgical techniques. Virtually all pedunculated polyps and the majority of benign sessile polyps can be excised colonoscopically, certain of the larger benign sessile polyps and all malignant sessile lesions still require partial colectomy, if the patient's general condition will permit. Preparation for colonoscopic polypectomy includes thorough mental as well as physical preparation of the patient and the availability of properly functioning endoscopic and snare-cautery equipment. An experienced colonoscopist is one who is not only prepared for the diagnostic possibilities but experienced enough to manage certain of the larger polyps so that laparotomy is limited to those few lesions that are not amenable to safe and total colonoscopic polypectomy.

Which colonic polyps should be excised endoscopically?

A review of 464 consecutive polypoid lesions of the colon reveals that virtually all pedunculated polyps and over 80% of 218 sessile polyps were removed colonoscopically. Although size or location of the lesions occasionally precludes colonoscopic excision, the endoscopic appearance of a sessile polyp is the most important factor in deciding upon the method of excision. In gneeral, smooth, soft, nonulcerated sessile lesions of all sizes were excised endoscopically, while approximately half of the larger (2-6 cm) firm, irregular-surfaced, benign sessile lesions, and all ulcerated or malignant sessile lesions required laparotomy for proper management. All polypoid lesions should be viewed endoscopically before deciding the method of excision, regardless of their size, location, or general appearnce by barium enema. Experience with endoscopic morphology and snare electrocautery technics was most important, since more than 85% of all polypoid lesions in this consecutive series were removed endoscopically.

Premalignant lesions of the colon

1. 1. This report presents a study of sixtyeight patients with adenomatous polyps of the colon excluding those of the rectum. 2. 2. The most frequent symptom, bleeding, was present in 80 per cent of the patients. 3. 3. In this series 48.5 per cent were diagnosed by sigmoidoscopic examination. The author believes that sigmoidoscopy is one of the most important examinations in the diagnosis and prophylaxis of cancer. 4. 4. Sigmoidoscopic and x-ray double contrast studies should be carried out in all patients in whom a polyp of the rectum or colon has been found. Multiple polyps were found in 17.6 per cent of the patients in this series. 5. 5. Simple excision of a pedunculated polyp is adequate if the pedicle is removed with its base. Wedge resection is advised for benign sessile lesions. Radical resection must be carried out if there is local invasion or metastases to regional nodes. 6. 6. The prognosis is excellent in those patients with benign polyps and in those in whom local non-invasive malignant change has taken place in the polyp. 7. 7. In no other branch of surgery can cancer prophylaxis and treatment be so successfully carried out as in the excision of polyps of the colon.

Simplified treatment of diaphragmatic rectal strictures.

The purpose of the present study is to report (1) our follow-up observations of electrosurgical resection of diaphragmatic strictures of the rectum and (2) to stress the necessity of histopathological examination of these lesions. In June, 1950, a preliminary report1was made on the electrosurgical resection of the following types of rectal strictures: (1) benign congenital; (2) benign postoperative; (3) inflammatory (caused by venereal lymphogranuloma); and (4) postoperative malignant (following so-called anterior resection). This resection was done by means of a double loop, high frequency resector that was originally designed for the extirpation of benign sessile rectal adenomas.1aWith this instrument, it is possible to remove tissue in which enough of the original architecture is preserved to make the specimen suitable for microscopic examination. The surgical literature of recent years does not record a similarly organized therapeutic plan. MATERIAL Benign Congenital Strictures.— The reported incidence of congenital fibrous

Intussusception

1. 1. Five cases of intussusception with intestinal tumors as etiological factors are reported. 2. 2. All intussusceptions should be carefully examined at the apex for tumors and if the attendant edema is so great that it is confusing, there should be no hesitancy in incising the intestine to facilitate exploration. 3. 3. All such tumors should be removed if the patient's condition does not prohibit it. 4. 4. The cautery may be used very efficiently to remove benign sessile growths, thus eliminating enterectomy and its greater mortality. 5. 5. The subject of intussusception is reviewed.

SUPRA-PUBIC CYSTOTOMY.

The personal experience upon which this report is based embraces twenty-three operations, in all of which recovery ensued. They may be, for purposes of study, divided into: 1. TUMORS. Case 1. —Male, aged 40. Operation July 7, 1888. Seven months before, haematuria, chills and fever. Diagnosis, cancer of bladder. Large epithelioma removed. Drainage tube removed eighth day. Urine ceased to escape through wound on sixteenth day. Recovery. Improved. Six months later, death from general metastasis and exhaustion. Case 2 .—Male, 36 years old. Operation July 20, 1888. Small benign sessile tumor removed from floor of trigonum. Drainage tube removed sixth day. Wound closed on eighteenth day. Recovered. Cured. Case 3 .—Female, 20 years old. Small, pedunculated, benign tumor at commencement of urethra, forming ball-valve, and stopping free outflow of urine. Operation March 26, 1889. Wound in bladder closed at once. Catheter per urethram ten days. No leakage. Recovery. Case 4 .—Male, 54 years. Operation