Neoplastic Polyps Research Articles

Malign Safra Kesesi Polipleri için Risk Faktörleri

PURPOSE: The aim of this study is to determine risk factors for malignancy in gallbladder polyps. METHODS: 92 patients who underwent laparoscopic cholecystectomy due to gallbladder polyp were retrospectively analyzed. Demographic data of the patients, size and number of polyp, the presence of gallstones and histopathological features of the polyps were recorded. RESULTS: 92 patients were included. Mean age was 45.78±11.21 years (21-72). 59 of the patients (64.1%) were female and 33 (35.9%) were male. Mean polyp size was 8.17±2.19 mm and 35 patients (38.0%) had a single polyp, while 57 (62.0%) had multiple polyps (≥2). 47 of the patients (51.1%) had gallstone disease, while 45 (48.9%) had no stone disease. Benign polyps (Group 1) were found in 79 patients (85.9%) and adenocarcinomas (Group 2) were found in 13 (14.1%). Of the benign polyps, 71 (77.1%) were non-neoplastic polyps and 8 (8.8%) were neoplastic polyps (adenomas). Of the 13 patients with adenocarcinomas, 11 (11.9%) were T1a and 2 (2.2%) were T1b. Mean age was 44.32±11.03 years in Group 1 and 54.61±8.07 years in Group 2, the latter being significantly older (p=0.002). Mean polyp size was 7.47±5.51 mm in Group 1 and 12.46±1.89 mm in Group 2, with a significant difference (p<0.001). The cut-off value to detect malignant polyps was a polyp size of 10.5 mm with 92.3% sensitivity, 84.8% specificity, and 0.934 accuracy (p< 0.001). The cut-off value to detect malignant polyps was an age of 50.5 years with 76.9% sensitivity, 67.1% specificity, and 0.767 accuracy (p=0.002). Polyp size and age were important risk factors for malignant gallbladder polyps (p<0.001, OR=2.313; 95% CI: 1.502–3.561), (p=0.004, OR=1.100, 95% CI: 1.030–1.175). CONCLUCISION: We recommend cholecystectomy for asymptomatic patients aged above 50 years with gallbladder polyps larger than 10 mm due to the increased risk of malignancy.

Application of artificial intelligence in pancreaticobiliary diseases.

The role of artificial intelligence and its applications has been increasing at a rapid pace in the field of gastroenterology. The application of artificial intelligence in gastroenterology ranges from colon cancer screening and characterization of dysplastic and neoplastic polyps to the endoscopic ultrasonographic evaluation of pancreatic diseases. Artificial intelligence has been found to be useful in the evaluation and enhancement of the quality measure for endoscopic retrograde cholangiopancreatography. Similarly, artificial intelligence techniques like artificial neural networks and faster region-based convolution network are showing promising results in early and accurate diagnosis of pancreatic cancer and its differentiation from chronic pancreatitis. Other artificial intelligence techniques like radiomics-based computer-aided diagnosis systems could help to differentiate between various types of cystic pancreatic lesions. Artificial intelligence and computer-aided systems also showing promising results in the diagnosis of cholangiocarcinoma and the prediction of choledocholithiasis. In this review, we discuss the role of artificial intelligence in establishing diagnosis, prognosis, predicting response to treatment, and guiding therapeutics in the pancreaticobiliary system.

Spectrum of gastrointestinal polyps: A tertiary care hospital experience of five years

Introduction: Polyps of gastrointestinal tract are not uncommon specimens received in surgical pathology laboratory. With advent of advanced endoscopy it is now possible to precisely sample polyps and determine its nature; weather benign, malignant or with malignant potential. Present study was performed with aim to study incidences of various histological types of polyps of gastrointestinal tract, to study its clinical presentation and to study polyps in relation to their size and site, in a tertiary care hospital. Materials and Methods: A retrospective and prospective analysis of 189 cases of gastrointestinal polyps was carried out over a period of eight and half years. Relevant clinical details of patient, size, number, size and presence of stalk etc. were noted. Specimens were studied for gross and microscopic examination after fixation of specimen with 10% formalin and microscopically examining H & E slides. They were classified according to site and various histological types. Results: Overall, we analysed 189 cases of gastrointestinal polyps. Commonest site was large intestine and commonest type was Juvenile polys, followed by neoplastic polyps, hyperplastic polyps, inflammatory pseudo polyps, hamartomatous polyps, inflammatory fibroid polyps and 2 cases of Familial polyposis coli were note. Conclusion: Present study reveals that gastrointestinal tract had wide spectrum of non-neoplastic as well as neoplastic polyps. They have different clinical significances and therapeutic implications. Histopathology play pivotal role in arriving at final diagnosis which enables to study detail incidences and helps to differentiate non-neoplastic diseases with clinical presentation of malignancy. Incidence of various polyps in based on institutional data and may not reflect incidence of state or nation. Keywords: Gastrointestinal polyps, Adenomatous polyps, Juvenile polyps, Neoplastic polyps.

Morphologic spectrum of gastrointestinal polyps and polypoid lesions - A five year study

Introduction: Polyps begin as small elevations of the mucosa and polyps are most common in the colorectal region. The neoplastic polyps are important because they have a risk of transformation into malignancy. The role of the Pathologist is to identify any dysplastic changes and inform the clinician regarding the risk of development of carcinoma. Materials and Methods: This is a retrospective analysis of polyps and polypoid lesions of 5 year duration from January 2013 to December 2017. The biopsies were stained with Haematoxylin & Eosin and studied under light microscope. Results: 107 cases of gastrointestinal polyps and polypoid lesions were included in our study. Hyperplastic polyps were the most common polyps found in our study. The most common site was rectum and stomach. Variety of lesions included in our study are multiple Peutz Jeghers (PJ) polyps, adenocarcinoma arising in PJ polyp, neuroendocrine tumours, and an angiomatous polyp. Conclusion: Gastrointestinal polyps are divergent lesions. Differentiation of neoplastic polyps from non-neoplastic polyps is important in view of adenoma- carcinoma sequence developing in neoplastic polyps. Identification of hamartomatous polyps is also crucial since they are associated with syndromes and may unusually transform in to cancers. Pathologists play a key role in diagnosis of neoplastic polyps and polyps associated with syndromes. In our study hyperplastic polyps were most common with a variety of other lesions. Keywords: Gastrointestinal polyps, Peutz Jeghers polyp, Peutz jeghers syndrome, Polypoid lesions.

Colonoscopy and Microscopy: Two sides of the coin- Our experience at Tertiary Care Centre in Central India

Introduction: The colonoscopy along with mucosal biopsy interpretation forms a prime diagnostic tool in work of patients with lesional diversity of colorectal region. The study was conduted to evaluate the histomorphological spectrum of colorectal lesions on colonoscopic biopsies and correlate the microscopy (histomorphology) with colonoscopic diagnosis offered. Materials and Methods: The material consisted of 168 colonoscopic biopsies which were submitted to the Department of Pathology, Govt. Medical College & Superspeciality Hospital, Nagpur during the period of Jan 2014 –Dec 2016. The histopathological classification of these lesions was based on WHO. Statistical analysis was done by Open Epi Info software. Result: Out of 168 colonoscopicbiopsies, 116 were non-neoplastic and 52 were neoplastic. A higher frequency of colonic diseases occur in males with male: female ratio -1.4:1 and the age range was between 2yrs to 92 yrs. Among the non-neoplastic lesions, ulcerative colitis was most common diagnosis, with frequent age group involved was 41- 50 yrs. Uncommon but interesting lesions like amoebic colitis (2 cases), pseudo membranous colitis(1 case), Melanosis coli (1 case) & congestive colopathy (1 case) were also found. Hyper plastic polyp & retention polyps were most common in non-neoplastic category while villous adenoma with dysplasia’s was most common in neoplastic polyps. Among the neoplastic lesions, conventional adenocarcinoma was the commonest subtype with rectum as the most common site. Conclusion: Colonoscopy & Microscopy are the two sides of the coin which can be used effectively together not only in diagnosis &treatment of colorectal lesions but alsosurveillance of inflammatory bowel disease. As 48% of overall malignant lesions occurred in less than 50yrs of age, due importance should be given to colonoscopic screening to detect early colorectal neoplasm. Keywords: Colonoscopy, Colorectal carcinoma, Dysplasia, Microscopy (histomrphology), Ulc

Overtreatment of Nonneoplastic Gallbladder Polyps due to Inadequate Routine Ultrasound Assessment

Background: The primary aim was to assess the diagnostic accuracy of routine ultrasound assessment for gallbladder polyps. The secondary aim was to identify the characteristics that differentiate neoplastic polyps from nonneoplastic polyps. Methods: A total of 156 patients with histopathologically proven gallbladder polyps in 4 Dutch hospitals between 2003 and 2013 were included. Sensitivity and specificity of ultrasound for polyp size, number of polyps, and polyp type were assessed using histopathological findings as a reference standard. In addition, diagnostic accuracy of sonographic size ≥1 cm for neoplasia was assessed. Subgroup analysis for patients with polyps as primary indication for cholecystectomy was performed. The sonographic polyp characteristics on preoperative routine ultrasound were described. Results: Fifty-six percent of gallbladder polyps were preoperatively identified on ultrasound, of which 31% were neoplastic. Sensitivity and specificity of ultrasound to estimate polyp size were 93 and 43% (subgroup; 92 and 33%). Sensitivity and specificity of sonographic polyp size ≥1 cm for neoplasia were 86 and 32% (subgroup; 94 and 26%). No specific sonographic characteristics for neoplastic polyps could be established due to lack of reporting. Conclusion: Routine ultrasound assessment of polyps is associated with overestimation of polyp size and low specificity of sonographic size ≥1 cm for neoplasia, which contributes to surgical overtreatment of nonneoplastic polyps.

The value of three narrow-band imaging model in the diagnosis of small colorectal polyps

This prospective study was aimed to evaluate the clinical value of narrow-band imaging (NBI), magnification endoscopy with narrow-band imaging (NBIME) and magnification endoscopy with acetic acid enhancement and narrow-band imaging (AA-NBIME) in the diagnosis of small colorectal polyps. We studied 261 small colorectal polyps from 122 patients with the use of above three techniques. Lesions were resected for histopathological analysis. The endoscopic images were independently reviewed by three experts and three non-experts and the diagnostic accuracy and image definition were compared among the modalities. The “experts-agreed” diagnostic accuracy was 87.7% for NBI versus 91.6% for NBIME versus 94.6% for AA-NBIME. The “non-experts-agreed” diagnostic accuracy was 80.1% for NBI versus 84.3% for NBIME versus 89.3% for AA-NBIME. All experts and non-experts diagnosed the small colorectal polyps statistically more accurately with AA-NBIME than NBI (P < 0.05). In all three modalities, the expert group’s diagnostic accuracies were statistically significantly higher compared with the non-expert group. For experts, the Kappa values for AA-NBIME, NBIME and NBI diagnosis were 0.962 (0.892–1.032), 0.577 (0.507–0.647) and 0.567 (0.497–0.637), respectively; while for nonexperts, 0.818 (0.748–0.888), 0.532 (0.462–0.602) and 0.530 (0.460–0.600). This demonstrated a good reproducibility of AA-NBIME diagnosis. The average scores (experts and non-experts) of images acquired using AA-NBIME were significantly higher than those acquired using NBIME and ME (P < 0.05). AA-NBIME is a promising tool to clearly visualize the mucosal pit pattern (PP) of colorectal polyps for better differentiating neoplastic polyps from non-neoplastic ones.

Pathohistology of polyps of the gastrointestinal tract

Polyps of the gastrointestinal tract encompass avariety of epithelial and non-epithelial tumour-like conditions. The most common polyps are epithelial lesions. In the upper gastrointestinal tract, reactive inflammatory changes and hyperplastic polyps dominate, whereas true neoplastic polyps, like adenomas, are much more common in the colorectum. In addition to neoplasias such as adenomas, non-neoplastic polyps such as hyperplastic polyps of the stomach may also be associated with an increased risk of malignancy. The risk of malignancy is determined by the histological subtype of polyp, as well as the size, presence and degree of dysplasia. The term "dysplasia" has been reintroduced for adenomas in the current 2019 World Health Organization (WHO) classification and replaces "intraepithelial neoplasia". Afurther change is the term "sessile serrated lesion" with and without dysplasia, which was formerly known as sessile serrated adenoma.

Low prevalence of colorectal neoplasia in microscopic colitis: A large prospective multi-center study

Background and AimsMicroscopic colitis (MC) is the most frequent condition in subjects undergoing ileocolonoscopy for chronic non-bloody diarrhea (CNBD) in Western countries. Emerging evidence has shown a negative association between MC and colorectal cancer. Within this prospective multi-center study we have evaluated the risk of colorectal neoplasia in MC and non-MC patients with CNBD receiving ileocolonoscopy with high-definition plus virtual chromoendoscopic imaging and histopathological assessment. MethodsPatients with CNBD of unknown origin were prospectively enrolled in 5 referral centers in Northern Italy for ileocolonoscopy with high-definition and digital/optical chromoendoscopy plus multiple biopsies in each segment. The prevalence of colorectal neoplasia (cancer, adenoma, serrated lesion) in MC was compared to that observed in a control group including CNBD patients negative for MC, inflammatory bowel disease or eosinophilic colitis. ResultsFrom 2014 and 2017, 546 consecutive CNBD patients were recruited. Among the 492 patients (mean age 53±18 years) fulfilling the inclusion criteria against the exclusion critieria, MC was the predominant diagnosis at histopathological assessment (8.7%: N=43, 28 CC, 15 LC). The regression model adjusted for age and gender showed a significant negative association between the diagnosis of CM and colorectal neoplasia (OR=0.39; 95% CI 0.22−0.67, p <0.001) with a 60% decreased risk of adenomatous and neoplastic serrated polyps as compared to the control group (n=412). ConclusionThis multi-center study confirms MC as a low-risk condition for colorectal neoplasia. No surveillance colonoscopy program is to be performed for MC diagnosis.

Low Risk of Neoplasia and Intraprocedural Adverse Events in Gastric Hyperplastic Polypectomy.

Assess neoplasia and polypectomy-related adverse event (AE) rates in gastric hyperplastic polyps (GHPs). GHPs carry a risk of neoplastic transformation. The rate of neoplastic transformation and the risk of polypectomy-related bleeding are unclear in the West, as data are derived from Asian or small studies. The authors aimed to determine the rate of dysplasia and intraprocedural AEs in GHP polypectomies in a western cohort. A retrospective study of 591 GHPs >1 cm resected in 491 patients in a single referral center on the occurrence of neoplasia and intraprocedural AEs. The mean age was 74.9±11.1 years, 57% female individuals. The mean polyp size was 2±0.8 cm. There were 11 neoplastic polyps (1.9%) with low-grade dysplasia, high-grade dysplasia, and cancer in 7 (1.3%), 2 (0.3%), and 2 (0.3%), respectively. Neoplasia was associated with age [9 (3.2%) for more than 75 years vs. 2 (0.7%) for less than 75 years; P=0.035], but not with polyp size or gender. Fifty patients (8.5%) had intraprocedural bleeding (IPB) requiring endoscopic intervention, with 3 hospitalizations. There were no perforations or procedure-related deaths. IPB was associated with polyp size and neoplasia. The adjusted odds ratio (95% confidence interval) for IPB was 1.63 (1.2-2.2) for a 1 cm increase in polyp size, and 7.4 (1.9-29.6) for the presence of neoplasia. The neoplasia rate in GHPs was 1.9%, lower than most previous reports, with no major intraprocedural AEs. Physicians may consider biopsy and follow-up in frail elderly patients, but the safety of this strategy needs further confirmation.

S0278 Adenoma and Sessile Serrated Detection Rates in Patients Undergoing Screening Colonoscopy Are Higher in Those Prepped With High-Volume Colonic Water Irrigation Than With Standard Oral Bowel Preparations

INTRODUCTION: Adenoma detection rate (ADR) is defined as the percentage of patients age 50 and older, with an average risk for colorectal cancer (CRC) who have adenomas detected on initial screening colonoscopy. ADR is an indicator of the adequacy of colonic preparation and skill level of the colonoscopist. Conventional adenomas have historically been considered to be the only screening-relevant CRC precursor lesion. However, sessile serrated polyps (SSPs) are considered to be a disproportionate contributor to interval CRC (subsequent to a colonoscopy). Quality of colonoscopy is critically dependent on the adequacy of colonic preparation. This study evaluated the adequacy of using high volume colonic water irrigation bowel prep (BP) on the detection rates of neoplastic polyps at the index screening exam. METHODS: ADR and detection rates of SSPs were collected at Austin Gastroenterology (Austin, TX) between October 1, 2018 and June 31, 2019. Study participants included 112 eligible and average risk patients. The high-volume colon irrigation was performed using an FDA-cleared system and under stringent standard operating procedures (SOP) by nurses and technicians trained by the managing operator. The study participants were examined by 18 gastroenterologists. RESULTS: ADRs of patients undergoing high-volume water irrigation BP was 34% in females and 60% in males. The detection rate for SSPs in patients who underwent high-volume water irrigation BP was 12.5%. The average Boston Bowel Prep Score (BBPS) was 8.3 (n = 112). CONCLUSION: When using a high-volume colonic water irrigation BP performed under stringent standard operating procedures the ADRs of patients was 34% in females and 60% for male, significantly exceeding the national guidelines for oral prep, 20% and 30%, respectively. The SSPs detection rate was also higher than the 5%–7% previously recorded in literature. Detection rate of colonic lesions is inversely related to the patient’s post-colonoscopy CRC risk, and improvement in methods and techniques to increase their detection rate will improve patient care. The FDA cleared high-volume colonic water irrigation, has outstanding BBPS scores, ADR, and SSP detection rates. Due to the increased quality of detection of neoplastic polyps, this approach should be considered a prep of choice for improved quality and outcomes.

S1840 An Interesting Case of a Polyp in an Inaccessible Location: A Tubulovillous Adenoma Found in the Appendiceal Orifice

INTRODUCTION: Primary adenocarcinoma of the appendix is a rare malignancy that accounts for less than 0.5% of all gastrointestinal malignancies. Of all appendiceal polyps, malignant adenomas of the appendix make up less than 0.1% of cases. We present an unusual case of a tubulovillous adenoma found in the appendix during a colonoscopy for evaluation of lower gastrointestinal bleed. CASE DESCRIPTION/METHODS: An 82-year-old man with a prior history of diverticular hemorrhage presented for complaints of hematochezia. A colonoscopy performed for evaluation revealed multiple diverticula. Incidentally, a 10 mm sessile polyp was seen at the appendiceal orifice extending into the appendiceal lumen. Biopsy of the lesion revealed tubulovillous adenoma. Patient subsequently underwent appendectomy and partial cecectomy. Pathology of the appendiceal specimen revealed a tubulovillous adenoma with moderate dysplasia. Citing age and personal reasons the patient has declined surveillance colonoscopy. He remains on aspirin for chemoprevention of further colonic polyps. DISCUSSION: Colonoscopy is the gold standard for screening and detection of neoplastic polyps to prevent their progression to carcinoma. Given the anatomy of the appendix and the difficulty of evaluating lesions extending into the appendiceal orifice, visualizing such lesions presents a tremendous challenge for endoscopists and are often missed during routine colonoscopy. While extremely rare, appendiceal polyps are often discovered accidentally during an appendectomy or incidentally at autopsy. Embryologically, the appendix is derived from the cecum and is thus histologically similar to colorectal tissue. 4.1% of patients with colorectal cancer also have synchronous appendiceal neoplasms. Recommended treatment is with appendectomy and, for malignant lesions, right hemicolectomy with subsequent surveillance colonoscopy. Overall five-year survival rate for appendiceal adenocarcinoma is 18.7%. However, this number jumps to 43.7% following curative resection. The difficulty of visualizing the appendix during colonoscopy has made detection of appendiceal neoplasms challenging. Furthermore, the association of colorectal cancer with appendiceal neoplasms and its favorable prognosis following resection, has placed an even greater emphasis on thorough visualization of the appendix during routine colonoscopy.Figure 1.: Sessile Polyp at the Appendiceal Orifice extending into Lumen.Figure 2.: Sessile Polyp at the Appendiceal Orifice extending into Lumen.

Recent Updates on Diagnosis, Treatment, and Follow-up of Gallbladder Polyps

A gallbladder (GB) polyp is an elevation of the GB mucosa that protrudes into the GB lumen. GB polyps have an estimated prevalence of 0.3-9.5% and can be divided into neoplastic (true) polyps and nonneoplastic polyps (pseudopolyps). Pseudopolyps are most commonly cholesterol polyps but also include focal adenomyomatosis and inflammatory polyps with no malignant potential. Neoplastic polyps, however, can be benign or malignant. Benign polyps are most commonly adenomas, while malignant polyps are usually adenocarcinoma. Transabdominal ultrasonography is the main radiological modality used for diagnosing and surveilling GB polyps. On the other hand, because it is difficult to diagnose GB polyps before surgery, alternative imaging modalities, such as endoscopic ultrasound, are being further evaluated. The current guidelines recommend cholecystectomy for GB polyps ≥ 10 mm in size as well as suboptimal sized GB polyps (6-9 mm) with other risk factors, including age >50, sessile, and symptoms. The quality of the evidence behind this practice is relatively low. Therefore, this review identifies the current gaps in the available evidence and guidelines and introduces methods that can help make decisions regarding patients who require a cholecystectomy or follow-up.

Real-time artificial intelligence–based histologic classification of colorectal polyps with augmented visualization

Artificial intelligence (AI)-based computer-aided diagnostic (CADx) algorithms are a promising approach for real-time histology (RTH) of colonic polyps. Our aim is to present a novel in situ CADx approach that seeks to increase transparency and interpretability of results by generating an intuitive augmented visualization of the model's predicted histology over the polyp surface. We developed a deep learning model using semantic segmentation to delineate polyp boundaries and a deep learning model to classify subregions within the segmented polyp. These subregions were classified independently and were subsequently aggregated to generate a histology map of the polyp's surface. We used 740 high-magnification narrow-band images from 607 polyps in 286 patients and over 65,000 subregions to train and validate the model. The model achieved a sensitivity of .96, specificity of .84, negative predictive value (NPV) of .91, and high-confidence rate (HCR) of .88, distinguishing 171 neoplastic polyps from 83 non-neoplastic polyps of all sizes. Among 93 neoplastic and 75 non-neoplastic polyps≤5mm, the model achieved a sensitivity of .95, specificity of .84, NPV of .91, and HCR of .86. The CADx model is capable of accurately distinguishing neoplastic from non-neoplastic polyps and provides a histology map of the spatial distribution of localized histologic predictions along the delineated polyp surface. This capability may improve interpretability and transparency of AI-based RTH and offer intuitive, accurate, and user-friendly guidance in real time for the clinical management and documentation of optical histology results.

Gallbladder polyps: Correlation of size and clinicopathologic characteristics based on updated definitions.

BackgroundDifferent perspectives exist regarding the clinicopathologic characteristics, biology and management of gallbladder polyps. Size is often used as the surrogate evidence of polyp behavior and size of ≥1cm is widely used as cholecystectomy indication. Most studies on this issue are based on the pathologic correlation of polyps clinically selected for resection, whereas, the data regarding the nature of polypoid lesions from pathology perspective -regardless of the cholecystectomy indication- is highly limited.MethodsIn this study, 4231 gallbladders -606 of which had gallbladder carcinoma- were reviewed carefully pathologically by the authors for polyps (defined as ≥2 mm). Separately, the cases that were diagnosed as “gallbladder polyps” in the surgical pathology databases were retrieved.Results643 polyps identified accordingly were re-evaluated histopathologically. Mean age of all patients was 55 years (range: 20–94); mean polyp size was 9 mm. Among these 643 polyps, 223 (34.6%) were neoplastic: I. Non-neoplastic polyps (n = 420; 65.4%) were smaller (mean: 4.1 mm), occurred in younger patients (mean: 52 years). This group consisted of fibromyoglandular polyps (n = 196) per the updated classification, cholesterol polyps (n = 166), polypoid pyloric gland metaplasia (n = 41) and inflammatory polyps (n = 17). II. Neoplastic polyps were larger (mean: 21 mm), detected in older patients (mean: 61 years) and consisted of intra-cholecystic neoplasms (WHO’s “adenomas” and “intracholecystic papillary neoplasms”, ≥1 cm; n = 120), their “incipient” version (<1 cm) (n = 44), polypoid invasive carcinomas (n = 26) and non-neoplastic polyps with incidental dysplastic changes (n = 33). In terms of size cut-off correlations, overall, only 27% of polyps were ≥1 cm, 90% of which were neoplastic. All (except for one) ≥2 cm were neoplastic. However, 14% of polyps <1 cm were also neoplastic. Positive predictive value of ≥1 cm cut-off -which is widely used for cholecystectomy indication-, was 94.3% and negative predictive value was 85%.ConclusionsApproximately a third of polypoid lesions in the cholecystectomies (regardless of the indication) prove to be neoplastic. The vast majority of (90%) of polyps ≥1 cm and virtually all of those ≥2 cm are neoplastic confirming the current impression that polyps ≥1 cm ought to be removed. However, this study also illustrates that 30% of the neoplastic polyps are <1 cm and therefore small polyps should also be closely watched, especially in older patients.

Intraperitoneal catheter introduction for pre-operative progressive pneumoperitoneum for abdominal hernia with loss of domain (Goni-Moreno technique).

Neoplastic gallbladder polyps (NGP) are rare; the prevalence in the overall population is less than 10%. NGP are associated with a risk of malignant degeneration and must be distinguished from other benign gallbladder polypoid lesions that occur more frequently. NGP are adenomas and the main risk associated with their management is to fail to detect their progression to gallbladder cancer, which is associated with a particular poor prognosis. The conclusions of the recent European recommendations have a low level of evidence, based essentially on retrospective small-volume studies. Abdominal sonography is the first line study for diagnosis and follow-up for NGP. To prevent the onset of gallbladder cancer, or treat malignant degeneration in its early phases, all NGP larger than 10 mm, or symptomatic, or larger than 6 mm with associated risk factors for cancer (age over 50, sessile polyp, Indian ethnicity, or patient with primary sclerosing cholangitis) are indications for cholecystectomy. Apart from these situations, simple sonographic surveillance is recommended for at least five years; if the NGP increases in size by more than 2 mm in size, cholecystectomy is indicated. Laparoscopic cholecystectomy is possible but if the surgeon feels that the risk of intra-operative gallbladder perforation is high, conversion to laparotomy should be preferred to avoid potential intra-abdominal tumoral dissemination. When malignant NGP is suspected (size greater than 15 mm, signs of locoregional extension on imaging), a comprehensive imaging workup should be performed to search for liver extension: in this setting, radical surgery should be considered.

Histopathologic features and fragmentation of polyps with cold snare defect protrusions

Cold snare defect protrusions (CSDPs) include muscularis mucosa (MM) and submucosa tissue. CSDPs are thought to result from fragmentation of the specimen during shallow excision. Our aim in this study was to clarify whether CSDPs are associated with polyp fragmentation. We retrospectively analyzed 1026 neoplastic colorectal polyps resected by cold snare polypectomy for which the presence or absence of CSDPs was assessed from the endoscopic image. All prepared specimens were reviewed and assessed for the presence or absence of polyp fragmentation, and the proportion of MM on the stump was measured. In addition, the risk factors for CSDP occurrence were evaluated. CSDPs occurred in 116 of the 1026 polyps (11.3%). Polyp fragmentation was significantly associated with the occurrence of CSDP on univariate analysis (odds ratio [OR], 3.74; P< .001) and multivariate analysis (OR, 3.13; P< .001). The proportion of MM >50% was significantly lower in the CSDP group than in the non-CSDP group (51.5% vs 70.9%, P< .001). CSDPs were significantly associated with a large polyp size (OR, 1.32; P= .007) and a large specimen size (OR, 1.24; P< .001) on multivariate analysis. The occurrence of CSDP was associated with less MM on the stump and fragmentation of the specimen.Clinically, the presence of CSDP is a good indicator of polyp fragmentation.

Adding efficiency to proficiency: a study of trainee polypectomy efficiency metrics.

Although validated colonoscopy assessment tools exist, they do not measure efficiency. This study aimed to assess content validity of polypectomy efficiency (PE) and neoplastic polypectomy efficiency (NPE) as colonoscopy efficiency indices. Data from a randomized controlled trial evaluating polypectomy among gastroenterology trainees were utilized. PE and NPE were defined as number of polyps (or neoplastic polyps) removed/withdrawal time × 100. Content validity was assessed by determining the association between efficiency indices and polypectomy times. 20 trainees performed 601 colonoscopies. There was a strong association between PE/NPE and actual polypectomy times: as polypectomy time increased by 1 minute, the PE decreased by 0.48 (P = 0.001) and NPE decreased by 0.24 (P = 0.03). The study proposed and provided content validity for PE and NPE as colonoscopy efficiency indices.

Mo1696 INCOMPLETE RESECTION OF 1–20 MM COLORECTAL POLYPS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Incomplete resection of neoplastic colorectal polyps can cause of post-colonoscopy colorectal cancer. This systematic review and meta-analysis aimed to determine the incomplete resection rate (IRR) of colorectal polyps and associated factors. We searched MEDLINE, EMBASE, EBM Reviews, and CINAHL to identify studies reporting on IRR of polyps 1-20mm published until March 2019. Exclusion criteria were: inclusion of inflammatory bowel disease cohorts; referrals for difficult polypectomy; polyp size >20mm; endoscopic submucosal dissection; conference abstracts; non-English language. The primary outcome was IRR based on histology assessment. Secondary outcomes included IRR for polyps 1-10mm and 10-20mm; IRR for different resection methods; and IRR based on method of assessing completeness. A total of 6148 records were identified and 37 studies with a total of 11,962 polyps were finally included in the quantitative analysis. The IRR for 1-20mm polypectomies (snare and forceps) was 10.54% (95% confidence interval [CI] 8.56-12.53) for studies using histologic assessment to determine incomplete resection status. Histologic IRR was 10.91% (95%CI 8.58-13.24) for polyps 1-10mm, 17.97% (95%CI 9.65-26.26) for polyps 10-20mm, 8.79% (95%CI 6.96-10.62) when snare polypectomy was used, and 17.75% (95%CI 10.49-25.01) when using forceps. Studies using only visual inspection with image-enhanced endoscopy to determine IRR reported a rate of only 0.69% (95%CI 0.02-1.35). Incomplete resection of 1-20mm colorectal polyps occurs frequently, with an increasing risk for polyps >10mm or when biopsy forceps are used. Visual inspection after polypectomy using only image-enhanced endoscopy likely underestimates the true IRR. Snare polypectomy results in lower IRR compared with forceps polypectomy.

Endoscopic Step Up: A Colon-Sparing Alternative to Colectomy to Improve Outcomes and Reduce Costs for Patients With Advanced Neoplastic Polyps.

The optimal strategy for colonic polyps not amenable to traditional endoscopic polypectomy is unknown. Endoscopic step up is a promising strategy for definitive treatment. The purpose of this study was to determine whether endoscopic step up leads to improved outcomes and decreased costs compared with planned colectomy for endoscopically unresectable colon polyps. This was a retrospective review of a prospective database. The study was conducted at a tertiary referral center. Consecutive patients referred for endoscopically unresectable colon polyps 15 to 50 mm in size were included. Patients underwent planned colectomy or endoscopic step up at the surgeon's discretion. Endoscopic step up began with diagnostic colonoscopy in the operating room. If the polyp was amenable to endoscopic removal, endoscopic mucosal resection or endoscopic submucosal dissection was performed with progression to combined endoscopic-laparoscopic surgery or laparoscopic colectomy, as indicated. The primary outcome was 30-day adverse events. We also examined length of stay, hospital charges, insurer payments, and polyp recurrence. A total of 52 patients underwent planned colectomy (48 laparoscopic), and 38 underwent endoscopic step up (28 endoscopic mucosal resection, 2 endoscopic submucosal dissection, 6 combined endoscopic-laparoscopic surgery, and 2 colectomy). Compared with planned colectomy, endoscopic step-up patients had fewer complications (13% vs 33%; p = 0.03) and shorter length of stay (median, 0 vs 4 d; p < 0.001). There was 1 readmission in the endoscopic step-up group and 5 in the planned colectomy group. Endoscopic step-up patients had lower hospital costs ($4790 vs $13,004; p < 0.001) and insurer payments ($2431 vs $19,951; p < 0.001). One-year polyp recurrence-free survival was 84% (95% CI, 67%-93%) in endoscopic step-up patients. All of the recurrences were benign, <1 cm, and managed endoscopically. The study was limited by its nonrandomized design and short follow-up. An endoscopic step-up approach to colon polyps is associated with less morbidity, decreased healthcare costs, and colon preservation in 95% of patients. Additional studies are needed to evaluate long-term quality of life and polyp recurrence in this group. See Video Abstract at http://links.lww.com/DCR/B188. UNA ALTERNATIVA A COLECTOMíA PARA PRESERVACIóN DE COLON CON LOS PROPóSITOS DE MEJORAR RESULTADOS Y REDUCIR COSTOS EN PACIENTES CON PóLIPOS NEOPLáSICOS AVANZADOS: Se desconoce la estrategia óptima para los pólipos de colon no susceptibles a la polipectomia endoscópica tradicional. Endoscopic Step Up es una estrategia prometedora para el tratamiento definitivo.Determinar si Endoscopic Step Up produce mejores resultados y menores costos en comparación con la colectomía programada para pólipos de colon endoscópicamente no resecables.Revisión retrospectiva de una base de datos prospectiva.Centro de referencia de tercer nivel.Pacientes consecutivos remitidos para pólipos de colon endoscópicamente irresecables de tamaño 15-50 mm.Los pacientes se sometieron a colectomía programada o Endoscópico Step Up a discreción del cirujano. Endoscopic Step Up comenzó con una colonoscopia diagnóstica en el quirófano. Si el pólipo era susceptible de extirpación endoscópica, la resección endoscópica de la mucosa o la disección submucosa endoscópica se realizaba con progresión a cirugía endoscópica-laparoscópica combinada o colectomía laparoscópica, según a cosnideraciones clínicas en el transoperatorio.El resultado primario fue los eventos adversos a 30 días. Duración de la estadía hospitalaria, los cargos hospitalarios, los pagos de las aseguradoras y la recurrencia de pólipos también fueron examinados.Un total de 52 pacientes se sometieron a colectomía programada (48 laparoscópicas) y 38 se sometieron a Endoscopic Step Up (28 resección endoscópica de la mucosa, 2 disección submucosa endoscópica, 6 cirugía endoscópica-laparoscópica combinada y 2 colectomía). En comparación con la colectomía programada los pacientes endoscópicos Step Up tuvieron menos complicaciones (13% versus 33%, p = 0.03) y una estadía hospitalaria más corta (mediana 0 versus 4 días, p <0.001). Hubo 1 reingreso hospitalario en el grupo Endoscopic Step Up y 5 en el grupo de colectomía programada. Los pacientes endoscópicos Step Up tuvieron costos hospitalarios más bajos ($ 4,790 versus $ 13,004, p <0,001) y pagos de la aseguradora ($ 2,431 versus $ 19,951, p <0,001). La supervivencia libre de recurrencia de pólipos a un año fue del 84% (IC 95% 67-93) en pacientes endoscópicos Step Up. Todas las recurrencias fueron benignas, <1 cm, y manejadas endoscópicamente.Diseño no aleatorizado y seguimiento corto.El abordaje endoscópico Step Up para pólipos de colon se asocia con menos morbilidad, disminución de los costos de atención médica y preservación del colon en el 95% de los pacientes. Se ocupan más estudios para evaluar la calidad de vida a largo plazo y la recurrencia de pólipos en este grupo. Consulte Video Resumen en http://links.lww.com/DCR/B188. (Traducción-Dr Adrián Ortega Robles).