Polyps of the biliary tract: is their preoperative diagnosis possible?

Bile duct polyps are a very uncommon cause of obstructive jaundice. We present our experience of three patients diagnosed in the last 10 years. Initial presentation usually takes the form of obstructive jaundice associated with abdominal pain, which simulates biliary lithiasis. The diagnosis is usually surgical. Although in some cases radiological studies and endoscopic retrograde cholangiopancreatography (ERCP) may sometimes detect bile duct polyps, exact diagnosis before surgery is very unusual. The radiological signs that suggest the existence of a bile duct polyp in the ERCP seem to be the presence of repletion defects, fixed unilaterally to the biliary conduit, without meniscus and without circumferential stenosis of the affected conduit. The most frequently found polyps are fibroinflammatory, and less frequently adenomatous.     

Endoscopic Mucosal Resection of Large Sessile Colorectal Polyps With Submucosal Injection of Hypertonic 50 Percent Dextrose–Epinephrine Solution

Purpose Before endoscopic mucosal resection of large sessile colorectal polyps, injection of solution into submucosa cushions and isolates the tumor, although there is little information as to which solution with optimal effect should be used. This study investigated the effectiveness of endoscopic mucosal resection by use of a hypertonic dextrose plus epinephrine solution for large sessile colorectal polyps. Methods We removed 59 large sessile colorectal polyps in 59 patients by introducing an endoscopic submucosal hypertonic dextrose plus epinephrine injection technique. Endoscopic evaluations were repeated at 3, 6, and 12 months or longer. If no residual tumor was observed endoscopically and histologically at one year or more, the patient was considered to be “cured.” The main outcome measurements were the mean amount of solution injected, mean disappearance time of solution, safety, complications, and recurrence at follow-up. Results Of the 59 large sessile colorectal polyps, 23 (39 percent) were resected en bloc and 36 (61 percent) piecemeal. The mean amount of hypertonic dextrose plus epinephrine solution injected was 24.42 ± 17.52 ml, and its mean disappearance time was 13.61 ± 5.21 (range, 7–21) minutes. Of the 36 patients treated with piecemeal resection, 18 (50 percent) required additional endoscopic interventions. In patients who entered the follow-up surveillance protocol for one year or longer, the cure rate by en bloc resection was 100 percent (23/23) and that by piecemeal intervention was 96.78 percent (30/31). Four patients (6.8 percent) had local bleeding after endoscopic mucosal resection that was mainly controlled endoscopically. Conclusions Endoscopic mucosal resection after submucosal hypertonic dextrose plus epinephrine solution injection, with an intensive follow-up program, seems to be a safe and effective treatment for large sessile colorectal polyps.     

Does Mutation of Transforming Growth Factor-β Type II Receptor Gene Play an Important Role in Colorectal Polyps?

Mutations in the transforming growthfactor- type II receptor (RII) gene that remainuncorrected due to mutation and inactivation of mismatchrepair genes play an important role in hereditarynonpolyposis colorectal cancer (HNPCC) and in a subset ofsporadic colorectal cancers. Some colorectal cancersdevelop from colorectal polyps. To elucidate the role ofthe RII gene in the generation of colorectal polyps, we analyzed 137 colorectal polyps from 100patients for RII mutations and microsatelliteinstability (MSI). MSI was detected in three of 36polyps from 25 patients. For one of these three polyps,the mobilities of the PCR products between polyp and nonpolyptissues was different for only one microsatellitemarker, and for the other two polyps the mobilities weredifferent for more than two markers. These two polyps were obtained from one patient with ascendingcolon carcinoma and suspected HNPCC based on hisclinical profile and family history. An RII mutation wasdetected in only one of these two polyps. RII may play a minor role in sporadic colorectalpolyps. RII gene analysis in colorectal polyps may be auseful screening measure for potential HNPCCpatients.     

Can Endoscopic Ultrasonography Differentiate Nonneoplastic from Neoplastic Gallbladder Polyps?

The present study aimed to clarify the endoscopic ultrasonography (EUS) features of nonneoplastic (cholesterol polyps and adenomyomatosis) and neoplastic (adenoma and adenocarcinoma) gallbladder polyps and to evaluate the effectiveness and limitation of EUS in the differential diagnosis of these lesions. We retrospectively compared EUS images with histologic findings in 29 surgical cases with gallbladder polyps with a diameter of 10 to 20 mm. Those cases were indicated for surgery based on the findings of a sessile appearance, a solitary lesion, low echogenicity, and/or a lobulated surface. Six of 10 cholesterol polyps were atypically seen as partially or completely hypoechoic due to predominant proliferation of glandular epithelia. Nine of 10 cholesterol polyps demonstrated an aggregation of hyperechoic spots, which represented multiple granules of cholesterosis. All adenomyomatoses (n = 10) showed multiple microcysts, which corresponded to proliferated Rokitansky-Aschoff sinuses. However, three of nine neoplastic lesions (three adenomas and six adenocarcinomas) showed one of these signs due to concomitant cholesterosis (n = 2) or proliferated Rokitansky-Aschoff sinuses (n = 1). In conclusion, 69% (20/29) of gallbladder polyps larger than 10 mm that were preoperatively suspected of malignancy were nonneoplastic. An aggregation of hyperechoic spots and multiple microcysts are considered to be important predictive factors for cholesterol polyps and adenomyomatosis, respectively. However, we should caution that these findings can also occur in neoplastic polyps when they contain a concomitant nonneoplastic component (cholesterosis or proliferated Rokitansky-Aschoff sinuses).     

Does Magnifying Narrow-Band Imaging or Magnifying Chromoendoscopy Help Experienced Endoscopists Assess Invasion Depth of Large Sessile and Flat Polyps?

Background

Distinguishing deep submucosa (SM) from superficial SM cancer in large sessile and flat colorectal polyps (>2 cm) is crucial in making the most appropriate therapeutic decision. We evaluated the additional role of magnifying narrow-band imaging (NBI) and magnifying chromoendoscopy (MCE) in assessing the depth of invasion in large sessile and flat polyps in comparison to morphological evaluation performed by experienced endoscopists.

Methods

From May 2011 to December 2011, a total of 85 large sessile and flat polyps were analyzed. Endoscopic features of the polyps were independently evaluated by experienced endoscopists. Subsequently, the polyps were observed using magnifying NBI and MCE.

Results

A total of 58 intramucosal lesions and 27 SM cancers (five superficial and 22 deep) were identified. The diagnostic accuracy of the experienced endoscopists, NBI, and MCE were 92.9, 90.6, and 89.4 %, respectively, for deep SM cancer. In combination with NBI or MCE, the diagnostic accuracy of the experienced endoscopists did not change significantly for deep SM cancer, with an accuracy of 95.3 % for both NBI and MCE.

Conclusions

Conventional colonoscopy can differentiate superficial from deep SM cancers with an accuracy of as high as 92.9 % in large sessile and flat polyps. Further diagnostic strategies are required in order to precisely assess the depth of invasion, especially in large colorectal polyps.     

Laparoscopic Colon Resection for Polyps: A Good Novice Case?

Purpose Laparoscopic colon resection of the endoscopically unresectable polyp has been considered an ideal case for the surgeon with moderate laparoscopic colectomy experience because tissues are not inflamed and the lymphadenectomy may not need to be as extensive compared with that required for cancer. To assess the appropriateness of this approach, we evaluated the incidence of invasive cancer in a series of laparoscopic colon resections for polyps. Methods A retrospective review was performed of 55 consecutive patients undergoing laparoscopic colon resection for endoscopically unresectable polyps during a 35-month period. Colonoscopy data, polyp characteristics, and final colon pathology were reviewed. Results On final pathologic examination, 18.2 percent of patients had invasive adenocarcinoma. Patient age, gender, indication for colonoscopy, polyp size, polyp location, polyp characteristics, and colonoscopic biopsy pathology were not predictive of adenocarcinoma on final pathology. Conclusions A significant number of endoscopically unresectable polyps harbor adenocarcinoma, thereby requiring a formal lymphadenectomy at resection. Caution should be exercised when considering the laparoscopic resection of an endoscopically unresectable polyp as a “learning” case. Poster presentation at The Society of American Gastrointestinal and Endoscopic Surgeons, Denver, Colorado, March 31 to April 4, 2004. Reprints are not available.     

What Is the Most Accurate Method for the Treatment of Diminutive Colonic Polyps?: Standard Versus Jumbo Forceps Polypectomy

Different methods such as standard, hot, and jumbo forceps are used in endoscopic treatment of diminutive colon polyps. In the current study, it was aimed to compare efficacy and safety of standard and jumbo forceps polypectomy methods in treatment of diminutive colon polyps of ≤5 mm. Polyps with ≤5 mm which were excised during colonoscopy by using standard or jumbo forceps were evaluated. Standard and jumbo forceps polypectomy methods were randomly performed in 212 consecutive patients with diminutive colorectal polyp. One-bite polypectomy and complete resection rates were also determined among polypectomy methods. Results of 161 standard forceps polypectomy and 102 jumbo forceps polypectomy were retrospectively evaluated. Both one-bite polypectomy and complete resection rates were significantly higher in the jumbo forceps polypectomy group than the standard forceps polypectomy group (P < 0.001). In the subgroup analysis performed according to polyp sizes, complete resection rate among polyps with 3-mm diameter was determined as 100%. However, numbers of bites in 4-mm and 5-mm polyps were higher in the standard forceps polypectomy group, and complete resection rate was lower than in the jumbo forceps polypectomy group (P < 0.001). Both endoscopic treatment methods may be employed in treatment of diminutive colon polyps with ≤5 mm. However, jumbo forceps polypectomy is a more effective treatment method in 4- to 5-mm polyps with high one-bite polypectomy and complete resection rate.     

Self-Formation Assessed by Cumulative Summation Test Does Not Reach Recommended Thresholds for Optical Diagnosis of Colorectal Polyps ≤ 7 mm

Background and Aims

Accurate optical diagnosis of diminutive polyps would allow implementing a resect and discard strategy. We evaluated the learning curve of a single training session followed by self-education in subjects with no endoscopic experience.

Methods

Learning curves were evaluated in 38 subjects employing learning curve–cumulative summation (LC‐CUSUM) tests, with each participant attending one training session regarding narrow band imaging and optical diagnosis and then individually assessing 100 lesions, receiving feedback after each diagnosis. Diagnostic accuracy was subsequently evaluated in 180 patients with lesions?≤?7 mm. Evaluators predicted each polyp’s histology and recommended a surveillance interval. Determinants of accuracy were explored using regression analysis.

Results

According to the LC‐CUSUM curve, 20 evaluators (52.6%) reached diagnostic competence after 57 lesions (IQR 55–76.5). During the diagnostic performance assessment, 11,666 diagnoses and 6840 follow-up recommendations were generated. Considering high confidence diagnoses, accuracy was 81.3% (80.5–82.1%), negative predictive value (NPV) for rectosigmoid adenomas 78.6% (76.4–80.6%), and sensitivity for adenomas 86.6% (85.8–87.4%). Two (5.3%) evaluators reached a?≥?90% accuracy, 3 (7.9%) presented a NPV for rectosigmoid adenomas?≥?90%, and 18 (47.4%) a sensitivity for adenomas?≥?90%. Multivariable logistic regression showed high confidence and size?≥?5 mm as the strongest predictors of accuracy. Fifteen (39.5%) evaluators recommended a correct or reduced follow-up interval in over 90% of subjects.

Conclusions

Self‐formation after a single training session did not allow most evaluators to reach the required accuracy. LC-CUSUM tests did not identify competent evaluators. Despite these results, 86.7% of follow-up intervals would have been corrected or reduced.

     

Differential Labeling by Monoclonal Antibodies Adnab-9 and Anti-α-Defensin 5 Based on the Distribution and Adenomatous Tissue Content of Colonic Polyps

We sought a correlation between site and morphology of colonic polyps by labeling with neoplastic and general Paneth cell markers, monoclonal antibodies Adnab-9 and anti--defensin 5, respectively. Proportions labeled by Adnab-9 and anti- -defensin 5 were, respectively, 42 and 85% for adenomas, 39 and 63% for early tubular adenomas, 41 and 44% for serrated, 34 and 20% for mixed, and 11 versus 2.7% for hyperplastic polyps. Compared with hyperplastic polyps, the proportion of other polyps labeled by Adnab-9 or anti--defensin 5 was higher but this difference was more significant for distal (P = 0.008 for Adnab-9 and P = 0.0001 for anti--defensin 5) than proximal (P = 0.645 and P = 0.154, respectively) polyps. While increased labeling of all proximal polyps compared to distal ones mirrored the colonic distribution of Paneth cells, distal adenomas tended to have a higher proportion labeled by Adnab-9, suggesting that Adnab-9 labels Paneth cells associated with increased neoplastic potential.     

Aspirin Desensitization: Useful Treatment for Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) in Aspirin-Exacerbated Respiratory Disease (AERD)?

Aspirin intolerance syndrome is due to disturbances in the arachidonic acid metabolism implicating both the lipoxygenase and cyclooxygenase pathways. This results in imbalances of eicosanoid, leukotriene and prostaglandin synthesis. Thus, preinflammatory cysteinyl leukotrienes increase and antiinflammatory prostaglandins (PG) such as PGE₂ decrease. Clinically, intolerance reactions to nonsteroidal antiinflammatory drugs (NSAIDs) can lead to different clinical manifestations; five phenotypes of the aspirin intolerance syndrome are listed in the ENDA classification. Aspirin-exacerbated respiratory disease (AERD) is the most common phenotype characterized by an eosinophil-dominated inflammatory disease of the airways that presents clinically with nasal polyps, chronic sinusitis and bronchial asthma. About 34 % of patients with aspirin-induced asthma and rhinosinusitis are thought to have AERD. Important biochemical findings in many AERD patients are increased basal leukotriene levels (at least in cell cultures) that excessively increase after intake of COX-1 inhibitors. Aspirin desensitization uses the repetitive application of aspirin to induce a tolerance to NSAIDs, especially COX-1 inhibitors. After a dose-increase phase reaching a threshold dose, a dose-continuation phase is performed. For application, the nasal, bronchial, oral and intravenous routes have been described. Aspirin desensitization has been proven to be efficacious and safe and was able to reduce the need for other medications in AERD patients.     

A survey of seroepidemiology of toxoplasmosis

The article reports the result of serological investigation on toxoplasmosis among human,animaland fowl populations in Huimin District,Shandong Province.2269 samples from 1471 people,133pigs,343 sheeps,127 goats,75 chickens and 120 rabbits were tested by IHA method.There were 7％positives found in human,2.5～11.3％ in domestic animals and fowls.with the highest incicencein pigs.There are marked difference in incidences between the group of farmers,cadres and the group     

Identification of protectective antigens of asexual stages of Plasmodium falciparum.

Seven monoclonal antibodies(McAbs)specific for Plasmodium falciparum from human immune seraof three individuals,two adults and one child(six years old),living in a malaria endemic area in Hainanprovince and immune sera of BALB/c mice immunized with the erythrocytic stages of P.falciparumwere used to identify the protective antigens present in the asexual blood stages of falciparum malaria.The McAbs designated 93A3,94B5,92D4 and 93D4 all immunoprecipitated the ~125I-labcled polypepti-des with apparent MWs of 125,115,83,74 and 67 KD.In addition,the 35S-methionine-labeled polype-