Large Sessile Colorectal Polyps Research Articles

Development and validation of an artificial intelligence-based system for predicting colorectal cancerinvasion depth using multi-modal data.

Accurate endoscopic optical prediction of the depth of cancer invasion is critical for guiding an optimal treatment approach of large sessile colorectal polyps but was hindered by insufficient endoscopists expertise and inter-observer variability. We aimed to construct a clinically applicable artificial intelligence (AI) system for the identification of presence of cancer invasion in large sessile colorectal polyps. A deep learning-based colorectal cancer invasion calculation (CCIC) system was constructed. Multi-modal data including clinical information, white light (WL) and image-enhanced endoscopy (IEE) were included for training. The system was trained using 339 lesions and tested on 198 lesions across three hospitals. Man-machine contest, reader study and video validation were further conducted to evaluate the performance of CCIC. The overall accuracy of CCIC system using image and video validation was 90.4% and 89.7%, respectively. In comparison with 14 endoscopists, the accuracy of CCIC was comparable with expert endoscopists but superior to all the participating senior and junior endoscopists in both image and video validation set. With CCIC augmentation, the average accuracy of junior endoscopists improved significantly from 75.4% to 85.3% (P=0.002). This deep learning-based CCIC system may play an important role in predicting the depth of cancer invasion in colorectal polyps, thus determining treatment strategies for these large sessile colorectal polyps.

Cold versus hot endoscopic mucosal resection for large sessile colon polyps: a cost-effectiveness analysis.

BACKGROUND : For large sessile colorectal polyps (LSCPs), endoscopic mucosal resection without diathermy ("cold endoscopic mucosal resection [EMR]") is gaining popularity because of its safety advantages over conventional EMR ("hot EMR"). Polyp recurrence rates have been reported to be higher with cold EMR. Considering these differences, we performed a cost-effectiveness analysis of these two techniques. METHODS : A decision analysis model was constructed for EMR of an LSCP. The decision tree incorporated the EMR method, clip use, procedural mortality, adverse events and their management, and polyp recurrence. Outcomes included days of lost productivity and marginal cost difference. Adverse event and recurrence rates were extracted from the existing literature, giving emphasis to recent systematic reviews and randomized controlled trials. RESULTS : Through 30 months of follow-up, the average cost of removing an LSCP by cold EMR was US$5213, as compared to $6168 by hot EMR, yielding a $955 cost difference (95 % confidence interval $903-$1006). Average days of lost productivity were 6.2 days for cold EMR and 6.3 days for hot EMR. This cost advantage remained over several analyses accounting for variations in recurrence rates and clip closure strategies. Clip cost and LSCP recurrence rate had the greatest and the least impacts on the marginal cost difference, respectively. CONCLUSION : Cold EMR is the dominant strategy over hot EMR, with lower cost and fewer days of lost productivity. In theory, a complete transition to cold EMR for LSCPs in the USA could result in an annual cost saving approaching US$7 million to Medicare beneficiaries.

First experience of one and two-step endoscopic submucosal dissection of colorectal neoplasms

Aim. To analyze the results of one and two-step endoscopic submucosal dissection in the treatment of colorectal neoplasms.
 Methods. Between 2018 and 2019, 17 patients (6 men and 11 women) aged 33 to 79 years underwent 21 endoscopic submucosal dissections of colorectal neoplasms ranging in size from 1.0 to 6.0 cm. Submucosal fibrosis was identified in 2 (11.8%) patients, epithelial neoplasms in 15 (88.2%) patients including laterally spreading tumors in 9 (60%), and large sessile colorectal polyps in 6 (40%) patients. Histological examination revealed a carcinoid tumor (11.8%), adenoma with low-grade (64.7%) and high-grade (23.5%) intraepithelial neoplasia. 13 patients were subjected to the one-step operation, and 4 patients required the two-step operation with a 1-day interval. Follow-up examinations after the operation were performed, on average, between 2 and 6 months.
 Results. En bloc endoscopic submucosal dissection was performed in 11 (64.7%) patients, 4 of them in combination with mucosal resection. Endoscopic piecemeal resection of the neoplasia was performed in 6 (35.3%) patients. The average operative time was 15573 minutes (range 40320 min). Intraoperative complications, which were eliminated endoscopically, occurred during 8 (38.1%) of 21 operations: intensive bleeding in 6 (75%) patients, diastasis of muscle fibers in 1 (12.5%) patient, perforation of the intestinal wall in 1 (12.5%) patient. At the follow-up at 6 months, all patients formed the scar at the surgical area, while 3 patients required endoscopic removal of residual adenoma 2 months after the operation.
 Conclusion. Endoscopic submucosal dissection is an effective method for removing colorectal neoplasms, while two-step dissection is a promising approach to the development of the technique.Keywords: one and two-step dissection, endoscopic submucosal dissection (ESD), colorectal neoplasms.

Underwater EMR of a colonic adenoma surrounded by diverticula.

An 83-year-old man with positive fecal occult blood test results underwent colonoscopy, which revealed a 15-mm-diameter laterally spreading tumor surrounded by multiple diverticula at the ascending colon (Figs. 1 and 2). The lesion was a nongranular-type laterally spreading tumor, and the Japanese Narrow-Band Imaging Expert Team classification was type 2A, meaning no evidence of invasion; therefore, we performed endoscopic resection instead of surgery.Figure 2Endoscopic image showing the tumor well demarcated with indigo carmine.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Conventional EMR of the tumor surrounded by diverticula with the use of submucosal saline solution injection would have been difficult because the appropriate lifting up by submucosal injection is difficult, and snaring including adjacent diverticula would have resulted in perforations. Furthermore, endoscopic submucosal dissection (ESD) for tumors adjacent to diverticula carries a high risk of perforation, and performing ESD on such lesions demands highly advanced skills, although we have reported success with the use of ESD for colonic polyps involving a diverticulum.1Shichijo S. Matsuno K. Takeuchi Y. et al.Pulley traction-assisted colonic endoscopic submucosal dissection affords good visibility of submucosal layer.VideoGIE. 2018; 3: 358-360Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,2Shichijo S. Yamasaki Y. Takeuchi Y. Case of colonic adenoma involving a diverticulum resected by a traction-assisted endoscopic submucosal dissection technique.Dig Endosc. 2017; 29: 729-730Crossref PubMed Scopus (17) Google Scholar Underwater EMR was developed and described by Binmoeller et al3Binmoeller K.F. Weilert F. Shah J. et al."Underwater" EMR without submucosal injection for large sessile colorectal polyps (with video).Gastrointest Endosc. 2012; 75: 1086-1091Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar in 2012. We previously reported the usefulness of this procedure with a high en bloc resection rate for intermediate-sized colorectal polyps4Yamashina T. Uedo N. Akasaka T. et al.Comparison of underwater vs conventional endoscopic mucosal resection of intermediate-size colorectal polyps.Gastroenterology. 2019; 157: 451-461.e2Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar; therefore, we performed underwater EMR for this lesion (Video 1, available online at www.VideoGIE.org). We here report the first case, to our knowledge, of a colonic adenoma surrounded by diverticula treated with underwater EMR. We used a magnifying colonoscope (Evis PCF-Q260ZAI; Olympus Medical Systems, Tokyo, Japan). Air was evacuated from the affected segment of the lumen and infused water until the lumen was completely full, after which we performed hot-snare polypectomy without submucosal injection, using a SnareMaster (15 mm; Olympus Medical Systems) (Fig. 3). A high-frequency electrical generator (Vio 300D; Erbe Elektromedizin, Tübingen, Germany) was used with the following settings: endocut Q mode: effect 3, duration 2, interval 4. We resected the lesion en bloc in 2 minutes without perforation and completely closed the mucosal defect with clips (Figs. 4 and 5). No adverse events occurred, and the patient experienced no postoperative abdominal pain or fever requiring antibiotics. On pathologic examination, the lesion was a tubular adenoma, high-grade in part, with negative margins (Fig. 6).Figure 4Endoscopic image showing completed underwater EMR.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Endoscopic image showing complete closure of the defect with clips.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Photograph of the specimen after it was resected en bloc in 2 minutes.View Large Image Figure ViewerDownload Hi-res image Download (PPT) All authors disclosed no financial relationships relevant to this publication. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJjOWE4NzBhZThjMTAyNjRmNTMyMWUzMThjM2U0OTJhNiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4MDA4Njc1fQ.ojSWMYGdEpn8sb_Vue33TsVsQk4sx0xrnjsYhN0e_DMlvnvbvi5PS7yv2mRUWzp3aWHkwZ4DJoK_nBNhCPKTdkB4F-kWgbyJUoHLKX-Wmq3WgmsVAB7rESbsA-KJA1m88IGz7HnhNTBBdva_Y-l26Ngn1miP5yyC9XT5ZVGfCjWvecCVo_hEJW_mHgjtsoOZ7OPrY-u8tb-Xx4tDpXt02RazLx4tDvP4H2nsA00kITkefKFvNuW-xE7zwOvGY82EkSh-eF7LSqwaA-uLhLrVmQb-OqrnZzW2Nxnbn-qa2NBulHuER2Ie6ppmB_x4TSRdEXfxLjxmy7Soh5Bp0OQrOA Download .mp4 (31.25 MB) Help with .mp4 files Video 1Underwater EMR of the colonic adenoma surrounded by diverticula.

Safety and efficacy of tip‐in endoscopic mucosal resection for large sessile colorectal polyps: A single‐center experience in Taiwan

AbstractEndoscopic mucosal resection (EMR) is an established technique for treating large colonic polyps. However, en bloc resection of large sessile lesions using conventional EMR is technically challenging and can generally be performed only in a piecemeal manner, resulting in low radical resection rates and high recurrence rates. Endoscopic submucosal dissection (ESD), a more difficult and time‐consuming technique, is an alternative procedure with high en bloc resection rates and low recurrence rates. Therefore, we present a novel technique: tip‐in EMR. We evaluated the feasibility and safety of tip‐in EMR for the en bloc resection of large sessile colorectal polyps or laterally spreading tumors (LSTs). In this retrospective observational study, we included patients who underwent tip‐in EMR for the removal of large colonic polyps (>10 mm) at Shuang Ho Hospital over a 2‐year period (September 2015 to September 2017). Clinical variables, including age, gender, polyp size and morphology, procedure time, complications, and pathology, were analyzed. A total of 46 polyps were removed from 42 adult patients through tip‐in EMR. The patients' mean ± SD age was 61.0 ± 12.0 years. The polyps were located in the right‐side colon, transverse colon, left‐side colon, and rectum in 39.1%, 17.4%, 37.0%, and 6.5% of the patients, respectively. The mean polyp size was 20.4 ± 5.6 mm (range = 10‐35 mm). LSTs were the predominant polyp type (n = 37, 81.5%). Among all LSTs (n = 37), 12 lesions were of granular type, and 25 lesions were nongranular. All polyps were removed en bloc using tip‐in EMR. The mean procedure time was 14.9 ± 8.8 min. Immediate bleeding occurred in only one patient (2.2%). No patient developed perforation or delayed bleeding. Regarding histopathological findings, 9 polyps (19.6%) were sessile serrated adenomas, 16 (34.8%) were tubular adenomas, 12 (26.1%) were tubulovillous adenomas, and 1 (2.2%) was a villous adenoma. High‐grade dysplasia was observed in four polyps (8.7%), and one lesion was an in situ carcinoma. Surveillance colonoscopy was performed in 20 patients (47.6%) over a mean follow‐up period of 12.7 ± 5.3 months. Among these patients, only one patient exhibited local recurrence. Tip‐in EMR is a novel alternative technique for polyp resection that is proven to be relatively safe and efficient for the en bloc removal of large sessile colonic polyps.

PTU-004 Safe and Effective Day Case Endoscopic Resection of Giant Colorectal Adenomas Greater than 8CM is Achievable in a Tertiary Referral Unit

Introduction There are few reports on the management of very large sessile colorectal polyps in western practice. Endoscopic resection of these lesions can be technically challenging and they have traditionally been subjected to surgical resection in western centres. Our aim was to determine the safety and effectiveness of endoscopic resection of giant colorectal polyps in a tertiary referral interventional endoscopy unit. Methods All lesions were assessed with magnification chromoendoscopy. Patients with colorectal polyps greater than or equal to 8 cm deemed suitable for endoscopic resection were included. Several techniques were employed including piecemeal endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and hybrid techniques involving EMR, ESD, transanal resection or transanal endoscopic microsurgery (TEMS). All patients underwent surveillance magnification chromoendoscopy at 3 and 12 months. Results 88 lesions greater than or equal to 8 cm were resected with a median size of 10 cm (range 8 cm-16cm). Mean age was 74 years. 49 lesions were in the rectum or rectosigmoid, 13 in the right colon and 27 in the descending and sigmoid colon. There were 6 tubular adenomas, 73 tubulovillous adenomas, 7 adenocarcinomas and 1 sessile serrated adenoma. The recurrence rate was 17%, 64% detected at the first surveillance endoscopy and 36% later recurrences. Of these, 2 patients required surgery in the form of TEMS and a right hemicolectomy, 1 died of unrelated causes, and the rest were managed with a repeat endoscopic resection and were free from recurrence at last surveillance. There were no clinically significant perforations. 3 perforations were closed with endoscopic clips and managed conservatively without complications. There were 2 unplanned admissions for bleeding which did not require further intervention. The recurrence and complication rate were significantly higher than for adenomas smaller than 8 cm. 72% were successfully completed as day cases. Of those patients without invasive cancer at their initial resection and alive at last follow up, 93% avoided surgery and were free from recurrence. Conclusion Successful endoscopic resection of giant colorectal adenomas is achievable in a western setting with a low risk of complications. In our series, none of 49 patients with rectal or rectosigmoid lesions, who would have traditionally required an anterior resection or abdominoperineal excision, required a major surgical resection. Almost all patients with benign polyps were successfully treated endoscopically and avoided surgery. Nonetheless, it is associated with a higher risk of complications and recurrence compared with lesions less than 8 cm and therefore should be considered in specialist units. Disclosure of Interest None Declared

Long-Term Outcome and Surveillance Colonoscopy after Successful Endoscopic Treatment of Large Sessile Colorectal Polyps.

PurposeAlthough there is a consensus about the need for surveillance colonoscopy after endoscopic resection, the interval remains controversial for large sessile colorectal polyps. The aim of this study was to evaluate the long-term outcome and the adequate surveillance colonoscopy interval required for sessile and flat colorectal polyps larger than 20 mm.Materials and MethodsA total of 204 patients with large sessile and flat polyps who received endoscopic treatment from May 2005 to November 2011 in a tertiary referral center were included.ResultsThe mean age was 65.1 years and 62.7% of the patients were male. The mean follow-up duration was 44.2 months and the median tumor size was 25 mm. One hundred and ten patients (53.9%) received a short interval surveillance colonoscopy (median interval of 6.3 months with range of 1-11 months) and 94 patients (46.1%) received a long interval surveillance colonoscopy (median interval of 13.6 months with range of 12-66 months). There were 14 patients (6.9%) who had local recurrence at the surveillance colonoscopy. Using multivariate regression analysis, a polyp size greater than 40 mm was shown to be independent risk factor for local recurrence. However, piecemeal resection and surveillance colonoscopy interval did not significantly influence local recurrence.ConclusionEndoscopic treatment of large sessile colorectal polyps shows a favorable long-term outcome. Further prospective study is mandatory to define an adequate interval of surveillance colonoscopy.

PWE-012 Outcomes of endoscopic mucosal resection of large (≥20 mm) sessile colorectal polyps in ysbyty gwynedd, north wales performed between january 2010 and may 2014: Abstract PWE-012 Table 1

<h3>Introduction</h3> Endoscopic mucosal resection (EMR) is an effective therapeutic technique for removal of large colorectal sessile polyps, and provides an alternative to surgery. To minimise the risks of serious complications only experienced and appropriately trained endoscopists should perform EMR. We aimed to evaluate the outcomes, major complications and recurrence rate for large (20 mm–39 mm) and giant (≥ 40 mm) sessile colorectal polyps. <h3>Method</h3> All EMRs for large ((≥ 20mm) sessile polyps performed between January 2010 and May 2014 were evaluated. The post-EMR major complications, recurrence rate and the technique (en bloc versus piecemeal resection) were analysed. This retrospective study was performed during two separate time periods. The initial study was performed for the polyps managed from January 2010 to December 2012. Post-analysis, specific recommendations were made, particularly to restrict the EMR to the experienced and appropriately trained endoscopists. The subsequent study was performed on the data collected between January 2013 and May 2014, and the comparison of the two studies confirmed better outcomes of the management of the polyps due to the recommendations made in the initial study. <h3>Results</h3> A total of 121 polyps were resected in 117 patients. There were 76 (64.95%) males and 41 females. Mean (± SD) age of the patients was 71.15 (± 10.13) years. There were 92 large polyps (76%) with a mean size of 26.93 (± 4.80) mm (range 20 – 39 mm), and 29 giant polyps (24%) with a mean size of 50.68 (± 12.79) mm (range 40 – 90 mm). The most frequent location was the sigmoid colon (24.79%). 42.14% of the total polyps were on the right side of colon. Enbloc resection was performed in 35 (29.91%) and piecemeal in 82 (70.08%). No immediate or delayed major bleeding occurred. One patient had bowel perforation. Two patients had intramucosal cancer, two had adenocarcinoma, and one patient had a rare finding of MALT lymphoma. Recurrence occurred in 6 polyps. <h3>Conclusion</h3> In our experience EMR- related major complications are low and comply with international standards. The technique requires an individualised approach by the experienced endoscopist, taking into consideration a thorough assessment of a particular patient and their polyp. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> British Society of Gastroenterology Guidelines American Society of Gastroenterology Guidelines

PTU-012 Endoscopic resection of giant colorectal adenomas greater than 8 cm – lessons from a tertiary referral practice

Introduction Patients with large sessile colorectal polyps can be technically challenging to resect endoscopically and have been subject to colorectal resection in the United Kingdom and in several centres in the Western world. Surgery can be associated with significant morbidity and mortality particularly in the elderly and in patients with rectal lesions. Our aims were to determine the safety and efficacy of endoscopic resection of large colorectal lesions at a tertiary referral unit. Method All patients with colorectal polyps greater than or equal to 8 cm deemed suitable for endoscopic resection were included in the study. Patients underwent magnification colonoscopy after dye spraying with 0.4% indigo carmine under midazolam sedation after oral bowel preparation. Snares were utilised for endoscopic mucosal piecemeal resection (EMR) and the Fuji flush knife for endoscopic submucosal dissection (ESD). The scar was examined with magnification chromoendoscopy post resection to check for residual disease. All patients underwent follow up magnification colonoscopy at 3 and 12 months by the same endoscopist. Results 84 endoscopic resections of lesions greater than or equal to 8 cm were undertaken, with a mean age of 72 years (SD 10.6). The location of lesions included rectum (n = 23); recto-sigmoid (n = 25); sigmoid (n = 26); descending colon (n = 2); ascending colon (n = 4) and caecum (n = 4). The mean size of the polyps was 102 mm. Histology revealed 78 tubulo-villous adenoma, 5 tubular adenomas and 1 adenocarcinomas. All lesions were resected completely with curative intent. There were 3 perforations (3.6%) all of which were closed endoscopically using clips without need for further surgery. One of the patients had evidence of post procedure haemorrhage. The local recurrence rate was 9.5%. The rate of complications and recurrence were significantly higher than that seen in patients with lesions less than 8 cm (n = 180). Conclusion Endoscopic resection of giant colorectal adenomas may be undertaken with low risk of complications thereby avoiding the need for surgical resection. Nonetheless, it is associated with a higher risk of complications, recurrence and admission to hospital when compared with lesions less than 8 cm and therfore should be considered in specialist units. Disclosure of interest None Declared.

Sa1564 Oral Anticoagulants Compared With Heparin Present Low Risk for Delayed Bleeding After Endoscopic Resection of Large Colonic Lesions

Sa1564 Oral Anticoagulants Compared With Heparin Present Low Risk for Delayed Bleeding After Endoscopic Resection of Large Colonic Lesions

Underwater colorectal EMR: remodeling endoscopic mucosal resection

Underwater EMR (UEMR) has been reported as a new technique for the removal of large sessile colorectal polyps without need for submucosal injection. To evaluate (1) outcomes of UEMR, (2) whether UEMR can be easily performed by an endoscopist skilled in traditional EMR without specific dedicated training in UEMR, and (3) whether EUS is required before UEMR. Prospective, observational study. Single, tertiary-care referral center. Underwater EMR. Complete resection and adverse events. A total of 72 consecutive patients underwent UEMR of 81 sessile colorectal polyps. EUS was performed before UEMR in 9 cases (11.1%) with a suspicious mucosal/vascular pattern. The mean polyp size was 18.7 mm (range 10-50 mm); the mean UEMR time was 11.8 minutes. Fifty-five polyps (68%) were removed en bloc, and 26 (32%) were removed with a piecemeal technique. Histopathology consisted of tubular adenomas (25.9%), tubulovillous adenomas (5%), adenomas with high-grade dysplasia (42%), serrated polyps (4.9%), carcinoma in situ (13.6%), and hyperplastic polyps (8.6%). Surveillance colonoscopy was scheduled at 3 months. Complete resection was successful in all patients. No adverse events or recurrence was recorded in any of the patients. Limited follow-up; single-center, uncontrolled study. Interventional endoscopists skilled in conventional EMR performed UEMR without specific dedicated training. EUS may not be required for lesions with no invasive features on high-definition narrow-band imaging. UEMR appears to be an effective and safe alternative to traditional EMR and could eventually improve the way in which we can effectively and safely treat colorectal lesions.

PWE-032 Endoscopic Resection Of Large Colorectal Polyps In A Tertiary Referral Unit Is Safe With A Low Risk Of Complications

IntroductionPatients with large sessile colorectal polyps can be technically challenging to resect endoscopically and have been subject to colorectal resection in the United Kingdom. Our aims were to determine the...

ClearPath-assisted underwater endoscopic mucosal resection of a laterally spreading tumor of the colon

A 50-year-old gentleman with a 4cm laterally spreading tumor of the sigmoid colon was referred to our institute for endoscopic resection. Biopsy of this lesion confirmed the presence of an adenomatous polyp with high-grade dysplasia. Based on the size and histology of the polyp, and in view of its location in the sigmoid colon, we opted to carry out underwater endoscopic mucosal resection (UEMR) [1]. This procedure was carried out with a high-definition narrowband endoscope (GIF-H190; Olympus Medical, Center Valley, PA, USA) equipped with a ClearPath cleaning device (EasyGlide Ltd., Kfar Truman, Israel) to facilitate water irrigation and aspiration during the procedure. With the help of the ClearPath, the colon was rapidly irrigated with water, allowing piecemeal UEMR. All the polyp fragments, regardless of size, were aspirated through the ClearPath suction channel into the central suction canister (● Fig.1,● Fig.2). The patient tolerated the procedure well with no adverse events recorded in the following days. UEMR of large sessile colorectal polyps without submucosal injection was described by Binmoeller et al. in 2012 [1]. In their experience, 60 consecutive patients with large sessile colorectal polyps undergoing UEMR had successful complete resection and no early complications. The ClearPath device has been developed for rapid luminal irrigation with high flow rates and efficient aspiration through its large suction channel (● Fig.2). This may allow evacuation of fluids, bile, and blood clots during upper gastrointestinal bleeding and has also been shown to be useful and safe for cleaning of poorly prepared porcine colon [2]. ClearPath-assisted underwater EMR allowed complete endoscopic resection while reducing procedure time due to fast colonic irrigation/aspiration and rapid polyp fragment retrieval. Although its efficacy cannot be fully demonstrated by a single report, this application of ClearPath appears useful and safe and may stimulate the development and manufacture of new, dedicated devices for UEMR.

Surveillance of Polypectomy Scars After Piecemeal Colon Polyp Resection

Previous studies suggest that during follow-up of patients at 3 to 6 months after piecemeal removal of large sessile colorectal polyps, biopsies of

PWE-043 The Management of Large Sessile Colorectal Polyps: Experience of a Single Welsh Screening Centre

IntroductionPrevious studies on large sessile colorectal polyps (LSCPs) suggest that management (Endoscopic vs Surgical) and outcomes (complication rates, incomplete resection, recurrence rates) may vary. The advent of the Bowel Cancer...

PTH-061 To Evaluate the Safety and Outcomes of Esd and Hybrid Esd for Large Sessile Colorectal Polyps Including Procedural Complications and Recurrence Rate

IntroductionThe purpose of ESD and Hybrid ESD (circumferential excision and snaring) is to obtain en bloc specimen. Margins are checked for residual tissue and APC applied if appropriateMethodsSingle endoscopist using...

506 Risk Factors for Intraprocedural and Clinically Significant Delayed Bleeding After Wide Field Endoscopic Mucosal Resection of Large Colonic Lesions: Results From a Multicenter Cohort of 1050 Patients

Risk Factors for Intraprocedural and Clinically Significant Delayed Bleeding After Wide Field Endoscopic Mucosal Resection of Large Colonic Lesions: Results From a Multicenter Cohort of 1050 Patients Nicholas G. Burgess*, Andrew J. Metz, Stephen J. Williams, Rajvinder Singh, William Tam, Luke F. Hourigan, Simon a. Zanati, Gregor J. Brown, Rebecca Sonson, Michael J. Bourke Gastroenterology, Westmead Hospital, Sydney, NSW, Australia; Gastroenterology, Lyell McEwin Hospital, Adelaide, SA, Australia; Gastroenterology, Princess Alexandra Hospital, Brisbane, QLD, Australia; Gastroenterology, Greenslopes Private Hospital, Brisbane, QLD, Australia; Gastroenterology, The Alfred Hospital, Melbourne, VIC, Australia; Gastroenterology, Western Hospital, Melbourne, VIC, Australia; Gastroenterology, Epworth Hospital, Melbourne, VIC, Australia Introduction: Wide Field Endoscopic Mucosal Resection (WF-EMR) for large colonic lesions is a safe and cost effective outpatient treatment. Clinically significant post EMR bleeding (CSPEB) following an uneventful procedure occurs in 7% and may be serious. Intraprocedural bleeding (IPB) occurs in 10% and is increasingly accepted as part of the procedure; however, difficult to control bleeding can result in patient morbidity. Few studies have examined risk factors for IPB or CSPEB following WF-EMR and there are no large prospective multicenter studies. Aims: We aimed to examine risk factors for IPB and CSPEB in a large cohort. Methods: Prospective multi-center data for WF-EMR of large sessile colorectal polyps or LSTs 20mm (June 2008-May 2012 ClinicalTrials.gov NCT01368289) were analysed. Data collection included patient and lesion characteristics, procedural events and outcomes, complications and scheduled follow-up at 14 days, 4 and 12 months. CSPEB was defined as bleeding requiring hospital admission after a completed procedure. IPB was defined as persistent bleeding 60sec requiring endoscopic intervention. Peri-procedural care was standardised. Standard EMR technique was used. Electrosurgical generators varied between centers. Results: WF-EMR was performed on 1139 lesions (mean size 35mm, right colon 52.9%) in 1050 patients (mean age 68 years). 102 patients had IPB (9.7%). Risk factors for IPB on multivariate analysis were younger age (Per decade OR 0.81 p 0.021), increasing lesion size (Per 10mm OR 1.26 p 0.001), Paris type IIa Is (OR 2.2 p 0.007), tubulovillous/villous histology (OR 1.8 p 0.015) and study institutions contributing fewer than 50 patients (OR 4.1 p 0.001). All IPB was successfully controlled (57% Thermal, 29% Clips alone, 12% Combined Clips/Thermal, 2% Adrenalin). 5 patients were admitted for observation following IPB. 62 patients had CSPEB (6.1%). On multivariate analysis right colon location predicted bleeding (OR 3.56, p 0.001) and use of EndoCut Q setting with ‘tapping’ footpedal technique was associated with less CSPEB than other methods combined (OR 0.53 p 0.019). Increasing age predicted bleeding presentation at 48 hours (Per decade OR 2.6 p 0.007). Lesion size, comorbidities, antiplatelet and anticoagulant use did not predict CSPEB. Use of 1:100,000 adrenalin in the EMR injectate did not reduce IPB (RR 0.91 p 0.10), but was associated with reduced CSPEB on univariate analysis (RR 0.58 p 0.036). IPB did not predict CSPEB (p 0.2). Conclusion: IPB occurs in 9.7% and is associated with younger age, increasing lesion size, tubulovillous or villous histology and Paris type IIa Is. CSPEB occurs in 6.1% and is more frequent in the right colon. CSPEB at 48hours is more likely with increasing age. Use of a microprocessor controlled electrosurgical generator with a ‘tapping’ technique is associated with less CSPEB.

Mo1195 The Management of Large Sessile Colorectal Polyps: Experience of a Single Welsh Screening Centre

Introduction Previous studies on large sessile colorectal polyps (LSCPs) suggest that management (Endoscopic vs Surgical) and outcomes (complication rates, incomplete resection, recurrence rates) may vary. The advent of the Bowel Cancer Screening Program (BSCP) provides opportunities to study this lesion subgroup systematically. We report the experience and outcomes of managing LSCPs in a single Welsh screening centre undertaking screening colonoscopy within an established local multidisciplinary discussion forum (colorectal surgery, endoscopy, radiology & histopathology). Methods Outcome data was collected prospectively for BSCP participants with a benign adenoma greater than 20mm between October 2009 and December 2011 in Cardiff and the Vale of Glamorgan. Each patient was discussed at a multidisciplinary team meeting. Standard protocol for piecemeal EMR or histology suggesting uncertain margins was to cheque the site at 3 months and 12 months post index therapeutic procedure. Results LCSP accounted for 3.42% of adenomas, mean size 32.2mm (1.02% were LSCP > 40mm). 33/40 (82.5%) LCSP were managed endoscopically, with either enbloc EMR, piecemeal EMR, or laparoscopically-assisted EMR. Of these, 84.8% had successful endoscopic resection with no recurrence at 3 to 12 months. Recurrent or residual polyp was detected in 1/28 (3.6%) at 3 months, with no recurrence at 12 months. 4/29 (13.8%) of lesions initially managed endoscopically subsequently required surgery. 3/4 (75%) went on to undergo TEM and 1/4 (25%) a segmental colonic resection. Indications included technical limitations to endoscopic management; difficult access or previous attempts at endoscopic resection at a different centre. No significant adverse events occured in the endoscopically managed group. There was a cancer rate (in lesions initially managed endoscopically) of 5.7% - no residual cancer was detected following definitive treatment. Surgery was the initial therapeutic modality in 7/40 (17.5%); 5/7 (71.4%) had segmental colectomy and 2/7 (28.6%) had TEM. No cancer was found in any surgically resected specimen. Conclusion Most patients with LSCPs can be managed endoscopically with good outcomes, including a low adverse event profile and recurrence rate. A small proportion of cases may turn out to have carcinoma that was not possible to diagnose in pre-procedure biopsies and thus require further surgery. Our study supports high quality endoscopic assessment and multidisciplinary team discussion as important factors in achieving optimal patient management and has resulted in piloting a change of practise across the BCSP to minimise variation in outcomes. Disclosure of Interest None Declared.

Continuing Medical Education Exam: June 2012

Instructions: The GIE: Gastroinintestinal Endoscopy CME Activity can now be completed entirely on-line. To complete do the following: 1. Read the CME article in this issue carefully and complete the activity: Kurien K, Evans KE, Hopper AD, et al. Duodenal bulb biopsies for diagnosing adult celiac disease: is there an optimal biopsy site? Gastrointest Endosc 2012;75:1190-6. Chokshi R, Hovis C, Hollander T, et al. Prevalence of missed adenomas in patients with inadequate bowel preparation on screening colonoscopy. Gastrointest Endosc 2012;75:1197-203. Vemulapalli KC, Rex DK. Failure to recognize serrated polyposis syndrome in a cohort with large sessile colorectal polyps. Gastrointest Endosc 2012;75:1206-10. Rondagh EJA, Bouwens MWE, Riedl RG, et al. Endoscopic appearance of proximal colorectal neoplasms and potential implications for colonoscopic cancer prevention. Gastrointest Endosc 2012;75:1218-25. 2. To date, ACC Sections and their Councils have been a valuable resource for the decision-making bodies of the College and have provided a welcome opportunity for the ACC to cultivate leadership and engage members. Visit the journals Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. To date, ACC Sections and their Councils have been a valuable resource for the decision-making bodies of the College. Exams can be saved to be acessed at a later date. ou may create a free personal account to save and return to your work in progress, as well as save and track your completed activities o that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME ctivities can also be found at this site.

Mo1402 Failure to Recognize Serrated Polyposis Syndrome in a Cohort With Large Sessile Colorectal Polyps

Mo1402 Failure to Recognize Serrated Polyposis Syndrome in a Cohort With Large Sessile Colorectal Polyps