Distal Colorectal Polyps Research Articles

Endoscopic mucosal resection (EMR) versus endoscopic submucosal dissection (ESD) for resection of large distal non-pedunculated colorectal adenomas

Background: Endoscopic mucosal resection (EMR) is currently the most used technique for resection of large distal colorectal polyps. However, in large lesions EMR can often only be performed in a piecemeal fashion resulting in relatively low radical (R0)-resection rates and high recurrence rates. Endoscopic submucosal dissection (ESD) is a newer procedure that is more difficult resulting in a longer procedural time, but is promising due to the high en-bloc resection rates and the very low recurrence rates. Objective: To investigate whether Endoscopic mucosal resection (EMR) is superior to endoscopic submucosal dissection (ESD) for resection of large distal non-pedunculated colorectal adenomas. Methods: PubMed, Google scholar and Science direct were searched using the following keywords: Endoscopic mucosal resection, endoscopic submucosal dissection and Colorectal adenomas. The authors also screened references from the relevant literature, including all the identified studies and reviews, only the most recent or complete study was included. Documents in a language apart from English have been excluded as sources for interpretation was not found. Papers apart from main scientific studies had been excluded: documents unavailable as total written text, conversation, conference abstract papers and dissertations. Conclusion: EMR is safe and effective for treating colorectal adenomas.

Leaving colorectal polyps in place can be achieved with high accuracy using blue light imaging (BLI).

A negative predictive value of more than 90% is proposed by the American Society of Gastrointestinal Endoscopy Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) statement for a new technology in order to leave distal diminutive colorectal polyps in place without resection. To our knowledge, no prior prospective study has yet evaluated the feasibility of the most recently introduced blue light imaging (BLI) system for real-time endoscopic prediction of polyp histology for the specific endpoint of leaving hyperplastic polyps in place. Prospective assessment of real-time prediction of colorectal polyps by using BLI. In total, 177 consecutive patients undergoing screening or surveillance colonoscopy were included. Colorectal polyps were evaluated in real-time by using high-definition endoscopy and the BLI technology without optical magnification. Before resection, the endoscopist described each polyp according to size, shape and surface characteristics (pit and vascular pattern, colour and depression), and histology was predicted with a level of confidence (high or low). Histology was predicted with high confidence in 92.5% of polyps. Sensitivity of BLI for prediction of adenomatous histology was 92.68%, with a specificity and accuracy of 94.87 and 93.75%, respectively. Following the recommendation of the PIVI statement, positive and negative predictive values were calculated with values of 95 and 92.5%, respectively. Prediction of surveillance based on both US and European guidelines was correctly predicted in 91% of patients. The most recently introduced BLI technology is accurate enough to leave distal colorectal polyps in place without resection. BLI also allowed for assignment of postpolypectomy surveillance intervals. This approach therefore has the potential to reduce costs and risks associated with the redundant removal of diminutive colorectal polyps.

Endoscopic mucosal resection (EMR) versus endoscopic submucosal dissection (ESD) for resection of large distal non-pedunculated colorectal adenomas (MATILDA-trial): rationale and design of a multicenter randomized clinical trial.

BackgroundEndoscopic mucosal resection (EMR) is currently the most used technique for resection of large distal colorectal polyps. However, in large lesions EMR can often only be performed in a piecemeal fashion resulting in relatively low radical (R0)-resection rates and high recurrence rates. Endoscopic submucosal dissection (ESD) is a newer procedure that is more difficult resulting in a longer procedural time, but is promising due to the high en-bloc resection rates and the very low recurrence rates. We aim to evaluate the (cost-)effectiveness of ESD against EMR on both short (i.e. 6 months) and long-term (i.e. 36 months). We hypothesize that in the short-run ESD is more time consuming resulting in higher healthcare costs, but is (cost-) effective on the long-term due to lower patients burden, a higher number of R0-resections and lower recurrence rates with less need for repeated procedures.MethodsThis is a multicenter randomized clinical trial in patients with a non-pedunculated polyp larger than 20 mm in the rectum, sigmoid, or descending colon suspected to be an adenoma by means of endoscopic assessment. Primary endpoint is recurrence rate at follow-up colonoscopy at 6 months. Secondary endpoints are R0-resection rate, perceived burden and quality of life, healthcare resources utilization and costs, surgical referral rate, complication rate and recurrence rate at 36 months. Quality-adjusted-life-year (QALY) will be estimated taking an area under the curve approach and using EQ-5D-indexes. Healthcare costs will be calculated by multiplying used healthcare services with unit prices. The cost-effectiveness of ESD against EMR will be expressed as incremental cost-effectiveness ratios (ICER) showing additional costs per recurrence free patient and as ICER showing additional costs per QALY.DiscussionIf this trial confirms ESD to be favorable on the long-term, the burden of extra colonoscopies and repeated procedures can be prevented for future patients.Trial registrationNCT02657044 (Clinicaltrials.gov), registered January 8, 2016.

In vivo real-time assessment of colorectal polyp histology using an optical biopsy forceps system based on laser-induced fluorescence spectroscopy.

In order to reduce time, costs, and risks associated with resection of diminutive colorectal polyps, the American Society for Gastrointestinal Endoscopy (ASGE) recently proposed performance thresholds that new technologies should meet for the accurate real-time assessment of histology of colorectal polyps. In this study, we prospectively assessed whether laser-induced fluorescence spectroscopy (LIFS), using the new WavSTAT4 optical biopsy system, can meet the ASGE criteria. 27 patients undergoing screening or surveillance colonoscopy were included. The histology of 137 diminutive colorectal polyps was predicted in real time using LIFS and findings were compared with the results of conventional histopathological examination. The accuracy of predicting polyp histology with WavSTAT4 was assessed according to the ASGE criteria. The overall accuracy of LIFS using WavSTAT4 for predicting polyp histology was 84.7 % with sensitivity, specificity, and negative predictive value (NPV) of 81.8 %, 85.2 %, and 96.1 %. When only distal colorectal diminutive polyps were considered, the NPV for excluding adenomatous histology increased to 100 % (accuracy 82.4 %, sensitivity 100 %, specificity 80.6 %). On-site, LIFS correctly predicted the recommended surveillance intervals with an accuracy of 88.9 % (24/27 patients) when compared with histology-based United States guideline recommendations; in the 3 patients for whom LIFS- and histopathology-based recommended surveillance intervals differed, LIFS predicted shorter surveillance intervals. From the data of this pilot study, LIFS using the WavSTAT4 system appears accurate enough to allow distal colorectal polyps to be left in place and nearly reaches the threshold to "resect and discard" them without pathologic assessment. WavSTAT4 therefore has the potential to reduce costs and risks associated with the removal of diminutive colorectal polyps.

High-definition endoscopy with digital chromoendoscopy for histologic prediction of distal colorectal polyps.

BackgroundDistal diminutive colorectal polyps are common and accurate endoscopic prediction of hyperplastic or adenomatous polyp histology could reduce procedural time, costs and potential risks associated with the resection. Within this study we assessed whether digital chromoendoscopy can accurately predict the histology of distal diminutive colorectal polyps according to the ASGE PIVI statement.MethodsIn this prospective cohort study, 224 consecutive patients undergoing screening or surveillance colonoscopy were included. Real time histology of 121 diminutive distal colorectal polyps was evaluated using high-definition endoscopy with digital chromoendoscopy and the accuracy of predicting histology with digital chromoendoscopy was assessed.ResultsThe overall accuracy of digital chromoendoscopy for prediction of adenomatous polyp histology was 90.1 %. Sensitivity, specificity, positive and negative predictive values were 93.3, 88.7, 88.7, and 93.2 %, respectively. In high-confidence predictions, the accuracy increased to 96.3 % while sensitivity, specificity, positive and negative predictive values were calculated as 98.1, 94.4, 94.5, and 98.1 %, respectively. Surveillance intervals with digital chromoendoscopy were correctly predicted with >90 % accuracy.ConclusionsHigh-definition endoscopy in combination with digital chromoendoscopy allowed real-time in vivo prediction of distal colorectal polyp histology and is accurate enough to leave distal colorectal polyps in place without resection or to resect and discard them without pathologic assessment. This approach has the potential to reduce costs and risks associated with the redundant removal of diminutive colorectal polyps.Trial registrationClinicalTrials NCT02217449.

853 Leaving Distal Colorectal Polyps in Place Can Be Achieved With High Accuracy Using High-Definition Endoscopy With Virtual Chromoendoscopy

The ASGE PIVI statement proposed that a new technology should provide a negative predictive value (NPV) >90% for adenomatous polyp histology to leave distal diminutive colorectal polyps in place without resection. To our knowledge no prior prospective study has yet evaluated the feasibility of virtual chromoendoscopy based, real-time endoscopic prediction of polyp histology for the specific endpoint of leaving distal hyperplastic polyps in place.

The Effect of Polyp Location and Patient Gender on the Presence of Dysplasia in Colonic Polyps

OBJECTIVE:There is increasing evidence of significant clinical and biological differences between proximal and distal colorectal polyps, as well as possible differences based on patient gender. There is a need to optimize and individualize screening strategies. We studied the potential influence of gender and of polyp location on the presence of dysplasia in colon polyps.METHODS:We used a prospective database on adenoma detection to identify patients. The primary outcome was the presence of dysplasia in colonic polyps. Covariates include age, gender, race, lesion size and site, and use of aspirin. Multivariate logistic regression analysis was used to analyze the relationship between the primary outcome and covariates. Results were reported as odds ratios (ORs), 95% confidence intervals (CIs), and P-values.RESULTS:A total of 2,400 patients (50.5% females and 49.5% males) completed colonoscopy for various indications. A total of 3,045 polyps were removed in 1,237 patients. Of those polyps, 54% (n=1,636) were on the right compared with 46% (n=1,409) in the left colon. The proportion of adenomas was significantly greater on the right colon when compared with the left: 69.4% vs. 39.3% (P=<0.0001). Multivariate logistic regression analysis showed that the right colon did have a significant association with dysplasia when controlling for age, gender, polyp size, and use of aspirin (OR=3.1 (95% CI: 2.3–4), P=<0.0001). Female gender was associated with decreased odds of finding dysplasia (OR=0.6 (95% CI: 0.46–0.78), P=0.03).CONCLUSION:Patient characteristics (male gender) as well procedure findings (increase polyp size and right-sided lesions) are associated with increased odds of dysplasia.

Leaving distal colorectal hyperplastic polyps in place can be achieved with high accuracy by using narrow-band imaging: an observational study

Accurate colonoscopic assessment of colorectal polyp histology could avoid resection of distal nonadenomatous polyps and reduce costs and risk. To assess the accuracy of predicting histology by using narrow-band imaging (NBI) in real time for distal colorectal polyps. Prospective observational study. University hospital and ambulatory surgery center. This study involved 225 consecutive adults undergoing elective screening or surveillance colonoscopy. We evaluated real-time histology of 235 distal (rectosigmoid) colorectal polyps from 31 patients by using high-definition colonoscopy and NBI without optical magnification. For each polyp, the endoscopist described size, Paris classification, and surface characteristics (vascular and pit pattern, color, pseudodepression). Before resection, histology was predicted, and a level of confidence (high or low) was assigned. Sensitivity and negative predictive value of high-confidence endoscopic predictions of adenomatous versus hyperplastic histology for polyps ≤ 5 mm. The accuracy of a high-confidence endoscopic prediction was 97.7%, sensitivity for adenomatous histology 93.9%, specificity 98.4%, negative predictive value 97.9%, and positive predictive value 75.6%. The performance characteristics for predicting diminutive distal polyps (≤ 5 mm) with high confidence were sensitivity 96.0%, specificity 99.4%, negative predictive value 99.4%, and positive predictive value 96.0%. Single-center study with a single endoscopist. NBI without optical magnification is sufficiently accurate to allow distal hyperplastic polyps to be left in place without resection and small, distal adenomas to be discarded without pathologic assessment. These findings validate NBI criteria based on color, vessels, and pit characteristics for predicting real-time colorectal polyp histology.

APC and KRAS mutations in distal colorectal polyps are related to smoking habits in men: results of a cross-sectional study

The purpose of this study was (a) to evaluate the association between cigarette smoking and the prevalence of distal colorectal polyps and adenocarcinoma and (b) to analyse genetic alterations representing different molecular pathways of the colorectal carcinogenesis. A total of 623 asymptomatic male (mean age: 53 years; 50-65) car factory workers were included. Information on smoking habits and other lifestyle factors were collected followed by a 60 cm colonoscopy. APC and KRAS mutations and microsatellite status were determined in colorectal lesions (colorectal carcinoma (CRC), hyperplastic (HP) and adenomatous polyps (AP)). Data were analysed using unconditional multiple logistic regression models. Smokers had a higher prevalence of AP (OR 2.1; 95% CI 1.2-3.6; p<0.05) and HP (OR 5.4; 95% CI 2.6- 11.1; p<0.05). No differences in CRC were observed. There was a dose-response relationship with the number of cigarettes smoked. The risk of developing AP or HP decreased after smoking cessation, even among heavy smokers (≥20 packs/year). KRAS mutations were more prevalent among smokers AP (OR 5.6; 95% CI 1.6-20.4; p=0.007). There was a trend of positive association with APC mutations (OR 3.5; 95% CI 0.9-4.4; p=0.096). APC and KRAS mutations were found in 36% and 61% of the HP of smokers, but were absent in non-smokers (p=0.89 and 0.78, respectively). There were no differences in MSI between smokers and non-smokers. Cigarette smoking is associated with a higher risk of developing both HP and AP and a higher prevalence of mutations in APC and KRAS.

Potential Short-Term Cost-Savings in the Management of Diminutive Distal Colorectal Polyps: Data From a ‘Real-Life’ Dutch Cohort

Potential Short-Term Cost-Savings in the Management of Diminutive Distal Colorectal Polyps: Data From a ‘Real-Life’ Dutch Cohort

Effectiveness of India ink as a long-term colonic mucosal marker.

We prospectively studied the use of India ink as a long-term or "permanent" mucosal marker as part of a study investigating the natural history of diminutive distal colorectal polyps. Twenty-six patients had 32 India ink tatoos implanted. The tatoo sites of the 19 patients who were followed at least 6 months continued to display intensely stained mucosa at the original sites. No side effects or complications were encountered. India ink appears to be a safe and effective long-term marker for colonic mucosal lesions.