Endoscopic resection for superficial colorectal neoplasia in Italy: A prospective multicentre study

BackgroundSince there are few prospective studies on colorectal endoscopic resection to date, we aimed to prospectively assess safety and efficacy of endoscopic resection in a cohort of Italian patients.MethodsProspective multicentre assessment of resection of sessile polyps or non-polypoid lesions ≥ 10 mm in size or smaller (if depressed). Outcome measures included complete excision, morbidity, mortality, and residual/recurrence at 12 months.ResultsOverall, 1012 resections in 928 patients were analysed (62.4% sessile polyps, 28.8% laterally spreading tumours, 8.7% depressed non-polypoid lesions). Lesions were prevalent in the proximal colon. Enbloc resection was possible in 715/1012 cases (70.7%), whereas piecemeal resection was required in 297 (29.3%). Endoscopically complete excision was achieved in 866 cases (85.6%). Adverse events occurred in 83 (8.2%), and no deaths occurred. Independent predictors of 12-month residual/recurrence were the location of the lesion in the proximal colon (OR 2.22 [95% CI 1.16–4.26]; p = 0.015) and piecemeal endoscopic resection (OR 2.76 [95% CI 1.56–4.87]; p = 0.0005). Limitations of the study were: potential expertise bias, no data on eligible and potentially resectable excluded lesions, high percentage of lesions < 20 mm, follow-up limited to 1 year.ConclusionIn this registry study the endoscopic resection of colorectal lesions was safe and achieved high rates of long-term endoscopic clearance.     

Colonic endoscopic mucosal resection of large polyps: Is it safe in the very elderly?

BackgroundOutcomes on colon endoscopic mucosal resection in the very elderly patient population are unknown.AimsAims of this study were to evaluate the outcomes and safety of colon endoscopic mucosal resection in this target population.MethodsObservational, retrospective study of patients ≥80 years of age that underwent colon endoscopic mucosal resection ≥2 cm. Demographics, American Society of Anesthesiologists classification, procedural data, and surgical treatment data were collected.ResultsOne-hundred-and-thirty-one colon endoscopic mucosal resections were performed on 99 patients ≥80 years of age with a mean age of 84. The majority of American Society of Anesthesiologists class was II. Mean lesion size was 3.3 cm (range, 2–12.5 cm), more procedures were performed in the right colon and adenoma/tubulovillous adenoma was the most common pathology. En bloc resection was performed on 26.7% of polyps (N = 35). Eight procedure-related adverse events (8/131, 6.1%) occurred. No anaesthesia related adverse events or deaths occurred. Six patients required a colonic operation, and overall, 94% of the patient cohort evaded a colon operation.ConclusionsColon endoscopic mucosal resection in very elderly patients can be performed at experienced endoscopy centres with a low rate of complications and offers these patients a non-surgical option of management of colorectal lesions.     

Long-term outcome of early gastric cancer after endoscopic submucosal dissection: Expanded indication is comparable to absolute indication

BackgroundEndoscopic submucosal dissection has become widely used for early gastric cancer with an expanded indication, although there is no strong consensus. We aimed to compare the clinical and long-term oncological outcome after endoscopic submucosal dissection according to indication.MethodsRetrospective review of 1152 patients with 1175 lesions who had undergone endoscopic submucosal dissection for early gastric cancer at tertiary educational hospital in Korea, between March 2005 and November 2011. Of these, 366 and 565 lesions were included in the absolute and expanded indication groups, respectively.ResultsEn bloc resection rates were not significantly different between the absolute and expanded indication groups. The complete resection rate was higher in the absolute indication group versus the expanded indication group (94.8% vs. 89.9%, respectively; P = 0.008). In the expanded indication group, complete resection rate was higher in the differentiated versus undifferentiated tumour subgroups (92.9% vs. 78.4%, respectively; P < 0.001). Recurrence rates were 7.7% in the absolute indication group vs. 9.3% in the expanded indication group (P = 0.524). Disease-free survival was not significantly different between the two indication groups (P = 0.634).ConclusionsEndoscopic submucosal dissection for early gastric cancer with expanded indication is a feasible approach to disease management. Periodic endoscopic follow-up is necessary to detect cancer recurrence.     

Endoscopic ultrasound-guided fine needle aspiration and biopsy using a 22-gauge needle with side fenestration in pancreatic cystic lesions

BackgroundCytologic diagnosis by endoscopic ultrasound-guided fine needle aspiration is associated with low sensitivity and adequacy. A newly designed endoscopic ultrasound-guided fine needle biopsy device, endowed with a side fenestration, is now available.AimsWe carried out a study with the aim of evaluating the feasibility, safety, and diagnostic yield of the 22-gauge needle with side fenestration for endoscopic ultrasound fine needle aspiration and biopsy of pancreatic cystic lesions.Methods58 patients with 60 pancreatic cystic lesions consecutively referred for endoscopic ultrasound guided-fine needle aspiration were enrolled in a prospective, dual centre study, and underwent fine needle aspiration and biopsy with the 22-gauge needle with side fenestration.ResultsFine needle aspiration and biopsy was technically feasible in all cases. In 39/60 (65%) pancreatic cystic lesions, the specimens were adequate for cyto-histologic assessment. In lesions with solid components, and in malignant lesions, adequacy was 94.4% (p = 0.0149) and 100% (p = 0.0069), respectively. Samples were adequate for histologic evaluation in 18/39 (46.1%) cases. There were only 2 (3.3%) mild complications.ConclusionsFine needle aspiration and biopsy with the 22-gauge needle with side fenestration is feasible, and superior to conventional endoscopic ultrasound-guided fine needle aspiration cytology from cystic fluid, particularly in pancreatic cystic lesions with solid component or malignancy, with a higher diagnostic yield and with no increase in complication rate.     

Clinical outcomes of endoscopic submucosal dissection (ESD) for treating early gastric cancer: Comparison with endoscopic mucosal resection after circumferential precutting (EMR-P)

BackgroundTo achieve en bloc resection for large lesions, endoscopic mucosal resection after circumferential precutting and endoscopic submucosal dissection techniques have been developed.AimTo compare endoscopic submucosal dissection with endoscopic mucosal resection after circumferential precutting in terms of the clinical efficacy and safety.Patients and methods346 consecutive patients underwent their first endoscopic mucosal resection after circumferential precutting (103 patients) or endoscopic submucosal dissection (243 patients) for early gastric cancer and their clinical outcomes were compared.ResultsFor early gastric cancer ≥20 mm endoscopic submucosal dissection group demonstrated significantly higher en bloc resection and en bloc plus R0 resection rate compared with endoscopic mucosal resection after circumferential precutting group. For early gastric cancer with size of 10–19 mm, endoscopic submucosal dissection group also showed significantly higher en bloc resection rate. For early gastric cancer <20 mm, however, en bloc plus R0 resection rate for endoscopic mucosal resection after circumferential precutting group was comparable to that for endoscopic submucosal dissection group. In case of R0 resection of intramucosal differentiated cancer, neither group showed local recurrence during the median 29 and 17 months of follow-up. Two groups did not show significant difference in the bleeding or perforation rates.ConclusionFor early gastric cancer <20 mm endoscopic mucosal resection after circumferential precutting may be considered as an alternative choice to endoscopic submucosal dissection. However, for early gastric cancer ≥20 mm endoscopic submucosal dissection should be considered as the first choice for treating early gastric cancer.     

Clinical outcomes of cap-assisted endoscopic resection for small rectal subepithelial tumors

ObjectiveTo assess the effectiveness and safety of cap-assisted endoscopic resection and the usefulness of endoscopic ultrasonography (EUS) for managing small rectal subepithelial tumors (SETs).Patients and methodsPatients with small rectal SETs ≤ 10 mm in diameter were enrolled in this study at our hospital from October 2014 to December 2017. First, EUS was performed to evaluate the lesions. Then, cap-assisted endoscopic resection was performed by suctioning the SET into a transparent cap, ligating with a metal snare and then resecting the tumor. The wound was closed using endoclips if necessary.ResultsForty patients were enrolled in the study. EUS showed lesions originating from muscularis mucosa or submucosa with an average diameter of 5.4 × 3.1 mm. The en bloc resection rate was 85.0% obtained by cap-assisted endoscopic resection, with a mean total procedure time of 17.6 min. No immediate perforation happened. Immediate bleeding occurred in five patients; all cases were managed successfully by endoscopy. No delayed bleeding was observed. Pathology examination showed that 70.0% of the lesions were neuroendocrine tumors (G1). One case of recurrence was seen in follow-up; it was managed successfully by endoscopic submucosal dissection. There was no tumor recurrence in a median follow-up period of 41 months in the remaining 39 patients.ConclusionsMost small rectal SETs arising from the muscularis mucosa or submucosa are neuroendocrine tumors and require proper treatment. Cap-assisted endoscopic resection is simple, effective and safe for resecting such lesions, and EUS is useful for case screening.     

Complications of endoscopic ultrasound fine needle aspiration on pancreatic cystic lesions: Final results from a large prospective multicenter study

BackgroundEndoscopic ultrasound-guided fine needle aspiration of pancreatic cystic lesions has been reported to have a higher complication rate than that of solid lesions, but the real complication rate is unknown. Aim of the study was to identify the complication rate of endoscopic ultrasound-guided fine needle aspiration and related risk factors.MethodsProspective multicenter study at four referral centres. Data were collected from January 2010 to July 2012, searching for all adverse events related to guided fine needle aspiration. All complications occurring up to day 90 were recorded.Results298 patients (43.9% male, mean age 63.2 ± 15.4 years) underwent endoscopic ultrasound-guided needle aspiration of pancreatic cystic lesions. Mean size was 34.1 ± 9 mm. Adverse events occurred in 18 patients (6%): mild complications in 12/18 (66.6%), and moderate complications in 6/18 (33.3%). Seven were immediate, 6 early, and 5 late. All resolved with medical therapy.ConclusionsEndoscopic ultrasound-guided fine needle aspiration of pancreatic cystic lesions has been found to be associated with a higher complication rate than for solid lesions; however, the risk rate is acceptable considering the complication grade and the important diagnostic role of the technique in the management of pancreatic cystic lesions.     

Obstructing giant post-inflammatory polyposis in ulcerative colitis: Case report and review of the literature

BackgroundPost-inflammatory polyps > 15 mm in diameter or length are termed “giant”. This benign and rare sequel of ulcerative colitis or colonic Crohn's disease can mimic colorectal carcinoma.ObjectiveTo illustrate this rare complication of inflammatory bowel disease and outline the characteristic radiological, endoscopic and histopathological features, by reviewing all previously published cases of giant post-inflammatory polyps in the English literature.ResultsReports of 81 giant post-inflammatory polyps in 78 patients were identified by systematic review of the literature. The incidence of giant post-inflammatory polyps is related to the extent of ulcerative colitis (incidence: 0%, 30%, and 70%, in proctitis, left-sided, and extensive disease, respectively). These lesions are typically located in the transverse or descending colon. Giant post-inflammatory polyps are as common in Crohn's disease (n = 36) as in ulcerative colitis (n = 42, 54%). Clinical presentations varies, including pain (n = 29), rectal bleeding (n = 20), diarrhoea (n = 19), luminal obstruction (n = 15), or a palpable mass (n = 11). Symptomatic presentation results in surgical resection. Clinical details and outcomes are comprehensively tabulated.ConclusionRecognition of this rare entity will prevent unnecessary radical surgical resection for presumed carcinoma. It highlights the need for clinical, radiological, endoscopic and histopathological correlation.     

Portal hypertensive colopathy and haematochezia in cirrhotic patients: An endoscopic study

Background and study aimsIn patients with liver cirrhosis, portal hypertensive colopathy (PHC) and anorectal varices (ARVs) are thought to cause lower gastrointestinal (GI) bleeding. In the present work, we studied the diagnostic yield of colonoscopy in cirrhotic patients and haematochezia.Patients and methodsThe current study was conducted on 77 consecutive cirrhotic patients who underwent colonoscopy at Mansoura Emergency Hospital, Egypt, between May 2007 and May 2011. Following rapid evaluation and adequate resuscitation, a thorough history was obtained with complete physical examination including digital rectal examination and routine laboratory investigations. Colonoscopic evaluation was performed for the included patients by recording endoscopic abnormalities and obtaining biopsies from lesions.ResultsThere was no significant difference between the PHC-positive group when compared with the PHC-negative group regarding patients’ age, sex, severity of haematochezia, positive family history and the history of intake of non-steroidal anti-inflammatory drugs (NSAIDs). Significant difference was noted regarding the Child–Pugh class (p < 0.05), history of splenectomy (p < 0.05), prior history of endoscopic sclerotherapy (EST) or endoscopic variceal ligation (EVL) (p < 0.05), prior history of upper gut bleeding (p < 0.05), the presence of gastric varices (GVs) (p < 0.05), presence of portal hypertensive gastropathy (PHG) (p < 0.05), presence of haemorrhoids (p < 0.05) and rectal varices (<0.05) and therapy with β-blockers (p < 0.05). Regarding the laboratory parameters, the platelet count only was markedly reduced in the PHC-positive group (p < 0.05). All the PHC-related sources of bleeding (7/32 cases (21.87%)) were successfully managed with argon plasma coagulation.Regarding the laboratory parameters, the platelet count only was markedly reduced in the PHC-positive group (p < 0.05).All the PHC-related sources of bleeding (7/32 cases (21.87%)) were successfully managed with argon plasma coagulation.ConclusionOur data revealed that it is not only PHC which is involved in haematochezia in cirrhotic patients despite the significant association. Instead, a high prevalence of inflammatory lesions came on the top of the list. Complete colonoscopy is highly advocated to detect probable proximal neoplastic lesions.     

What is the next step for gastric atypical epithelium on histological findings of endoscopic forceps biopsy?

BackgroundGastric atypical epithelium on endoscopic biopsy is borderline lesions between benign and malignant. Definitive management of this lesion remains debatable.AimsWe aimed to analyze the final histological diagnosis for atypical epithelium on endoscopic biopsy and to examine the discrepancy rate between the final histological diagnosis and the initial endoscopic assessment.MethodsThis retrospective study finally enrolled 24 cases proven atypical epithelium on initial histology of an endoscopic biopsy. Of 24 cases, endoscopic submucosal dissection (n = 22), operation (n = 1) and follow-up biopsy without endoscopic submucosal dissection (n = 1) were performed.ResultsOf the 24 cases, early gastric cancer (n = 15, 62%) and adenoma (n = 7, 30%) lesions were finally diagnosed in 22 cases. Age, sex, endoscopic results and number of biopsy did not significantly influence the result of final outcome. Between the initial endoscopic assessment and the final histological diagnosis, 12 cases (50%) showed a concordant diagnosis, but eight (33%) and four cases (17%) showed upgraded and downgraded diagnoses, respectively.ConclusionsOf atypical epithelium cases, the rate of malignant and premalignant lesions was 92% and it was difficult to distinguish between malignant and benign lesions using the initial endoscopic findings. Therefore, endoscopic submucosal dissection can be considered in patients with atypical epithelium on endoscopic biopsy.     

Fecal calprotectin one year after ileocaecal resection for Crohn's disease — A comparison with findings at ileocolonoscopy

Background and AimsIleocaecal resection for Crohn's disease is commonly performed. The severity of endoscopic lesions in the anastomotic area one year postoperatively is considered to reflect the subsequent clinical course.Fecal calprotectin (FC) has been shown to correlate with the findings at ileocolonoscopy in Crohn's disease. The objectives of this study were to assess whether the concentration of FC reflects the endoscopic findings one year after ileocaecal resection and to evaluate the variation of FC in individual patients during 6 months prior to the ileocolonoscopy.MethodsThirty patients with Crohn's disease and ileocaecal resection performed within one year were included. Stool samples were delivered monthly until an ileocolonoscopy was performed one year postoperatively.ResultsOne year after surgery the median values of FC were not significantly different between the patients in endoscopic remission (n = 17) and the patients with an endoscopic recurrence (189 (75–364) vs 227 (120–1066)μg/g; p = 0.25). However, most patients with low values were in remission and all patients with high (> 600 μg/g) calprotectin values had recurrent disease. The variability of the FC concentration was most pronounced in patients with diarrhea.ConclusionsWe found no statistical difference in the concentrations of calprotectin between patients in endoscopic remission and patients with a recurrent disease one year after ileocaecal resection for Crohn's disease. However, among the minority of patients with low or high values, FC indicated remission and recurrence, respectively. There was significant variation of the fecal calprotectin concentrations over time, which affects the utility of calprotectin in clinical practice.     

Clinical utility of the SMSA grading tool for the management of colonic neoplastic lesions

BackgroundWhilst polyp size has been traditionally used as a predictor of the complexity of endoscopic resection, the influence of other factors is increasingly recognised. The SMSA grading system takes into account polyp Site, Morphology, Size and Access, with higher scores correlating with increased technical difficulty.AimsTo evaluate whether the SMSA grading tool correlates with endoscopic and clinical outcomes.MethodsThis retrospective study was conducted at two high volume centres in the United Kingdom and Italy. All polyps identified at colonoscopy were included in this study and classified as per the SMSA grading system.ResultsA total of 1668 lesions were resected in 1016 patients. There was a positive correlation between increasing SMSA level and the inability to resect lesions “en bloc” (p < 0.001). Histologically complete clearance was higher in the lower SMSA groups (p < 0.0001). Additional endoscopic therapies, were more commonly required with the higher SMSA groups to achieve histological clearance (p < 0.0001). Moreover, advanced histology in resection specimens and procedural complications were significantly less common in SMSA level 1 lesions compared to level 3 or 4 lesions (p < 0.0001).ConclusionsThe SMSA grading tool is a useful predictor of outcome following the resection of colonic neoplastic lesions.     

Helicobacter pylori eradication on iatrogenic ulcer by endoscopic resection of gastric tumour: A prospective,randomized, placebo-controlled multi-centre trial

IntroductionThe role of Helicobacter pylori (H. pylori) eradication has not been clarified in the healing of iatrogenic ulcer after endoscopic resection of gastric neoplasm. The aim of this study was to evaluate whether H. pylori eradication could facilitate the healing of iatrogenic ulcer after endoscopic resection of gastric neoplasm.MethodsA total of 232 patients with H. pylori-positive early gastric cancer or gastric adenoma underwent endoscopic resection and were randomly allocated to eradication or placebo group in a prospective, double-blinded, and placebo-controlled manner. The primary outcome was measured by healing rate of ulcer, and the secondary outcomes by reduction rate of ulcer size, relief rate from ulcer-related symptoms, and adverse event rates.ResultsThe healing rate of ulcer was 53% in eradication group and 51.6% in placebo group, respectively (p value = 0.95). The reduction rate of ulcer size, relief rate from ulcer-related symptoms and adverse event rates were also not different between two groups. In multivariate analysis, initial ulcer size more than 3 cm and histology of cancer were significant factors affecting iatrogenic ulcer healing.ConclusionsH. pylori eradication did not facilitate iatrogenic ulcer healing at early and late phase after endoscopic resection of gastric neoplasm.     

Frecuencia de visualización de ganglios celíacos por ultrasonido endoscópico y su potencial en la evaluación de invasión neural en pacientes con lesiones pancreáticas

BackgroundCeliac ganglia (CG) can be seen by endoscopic ultrasound; they play an important role in pain management and are a potential site for extrapancreatic tumor neural invasion.AimsTo evaluate the frequency of CG visualization during endoscopic ultrasound examination and to evaluate the feasibility of this technique to identify extrapancreatic tumor neural invasion in patients with pancreatic lesions.MethodsWe retrospectively reviewed all endoscopic ultrasound studies performed between November 2007 and June 2010. Images of the celiac region were presented to an endosonographer, who reported the presence or absence of CG.ResultsWe included 31 cases. CG were identified in 14 (45%) cases. Average size was 10 mm (range 4-25 mm) by ± 1 mm (range 1-7 mm). In 2 cases, fine needle aspiration biopsy was performed and reported nerve cell bodies; in one case malignant cells were seen.ConclusionsCG were identified in 45% of the cases. Fine needle aspiration biopsy can detect unanticipated extrapancreatic tumor neural invasion in pancreatic malignancies.     

ERCP-induced and non-ERCP-induced acute pancreatitis: Two distinct clinical entities with different outcomes in mild and severe form?

BackgroundAcute pancreatitis is a complication of endoscopic retrograde cholangio-pancreatography. Aim of the study was to compare endoscopic retrograde cholangio-pancreatography-related acute pancreatitis with attacks caused by other factors.MethodsA series of consecutive patients with non-endoscopic retrograde cholangio-pancreatography-related acute pancreatitis referred to our hospital in 2007–2008 were examined retrospectively, and compared with the same number of patients with post-endoscopic retrograde cholangio-pancreatography acute pancreatitis done in the same institution. Both groups comprised 116 patients and were comparable for mean age, sex, and body mass index. Duration of abdominal pain, pancreatic enzyme elevation, hospital stay, and type of analgesia administered were retrieved.ResultsThere were no differences between the groups as regards the severity of pancreatitis, mortality rate and hospitalisation, although mortality was double in severe post-endoscopic retrograde cholangio-pancreatography acute pancreatitis. In the mild acute pancreatitis cases, serum amylase fell 50% from the peak in a mean of 46.4 h (range 24–72) in group 1 and 38.9 h (range 24–72) in group 2 (p < 0.001). The peak amylase serum level halved within 48 h in 73.6% of cases with non-endoscopic retrograde cholangio-pancreatography-related acute pancreatitis, and in 92% of patients with endoscopic retrograde cholangio-pancreatography-related acute pancreatitis (p < 0.001).ConclusionsNon-endoscopic retrograde cholangio-pancreatography- and endoscopic retrograde cholangio-pancreatography-induced pancreatitis did not differ as regards severity, hospital stay or mortality; in mild pancreatitis, serum amylase halved significantly sooner in post-endoscopic retrograde cholangio-pancreatography cases.     

The contribution of clinical and pathological predisposing factors to severe gastro-duodenal lesions in patients with long-term low-dose aspirin and proton pump inhibitor therapy

BackgroundPreventive strategies developed to avoid the complications of antiplatelet therapies recommend the evaluation of risk factors for gastrointestinal events and indicated gastroprotective strategies.AimWe aimed to assess the impact of predisposing factors - histological findings, concomitant drug consumption, comorbidities, symptoms, social habits, Helicobacter pylori infection - on severe gastro-duodenal lesions in patients with low-dose aspirin and concomitant protective therapy with proton pump inhibitors (PPI).MethodWe enrolled 237 patients with LDA and PPI therapy, referred for upper digestive endoscopy, divided into two groups according to the severity of their endoscopic lesions (172 patients with no or mild endoscopic lesions and 65 patients with severe endoscopic lesions).ResultsIn the univariate logistic regression model, the factors associated with severe gastro-duodenal lesions were gender (OR = 1.87, 95% CI: 1.04–3.41), anticoagulants (OR = 2.40, 95% CI: 1.26–4.53), gastric atrophy and/or intestinal metaplasia (OR = 1.85, 95% CI: 1.04–3.32), congestive heart failure (OR = 2.59, 95% CI: 1.16–6.62), anaemia (OR = 3.01, 95% CI: 1.67–5.47) and smoking (OR = 4.29, 95% CI: 1.57–12.32). In the final model, anticoagulants (p = 0.041 < 0.05) and anaemia (p = 0.019 < 0.05) were risk factors for severe lesions via multivariate regression analysis, while for active/inactive chronic gastritis and smoking a positive dependency with a tendency towards statistical significance (p < 0.10) was noticed for severe gastric lesions.ConclusionsIn patients treated with low-dose aspirin and gastroprotective therapy with proton pump inhibitors we have enough evidence to consider co-treatment with anticoagulants and anaemia important predictors for severe endoscopic lesions, while other factors such as inflammation in gastric biopsies, congestive heart failure, co-treatment with clopidogrel and smoking tended to have a positive influence on risk for severe gastro-duodenal lesions.     

Development of knowledge-based clinical decision support system for patients included in colorectal screening program

Background & aimsColorectal (CRC) screening programs represent a large volume of procedures that need a follow-up endoscopy. A knowledge-based clinical decision support system (K-CDSS) is a technology which contains clinical rules and associations of compiled data that assist with clinical decision-making tasks. We develop a K-CDSS for management of patients included in CRC screening and surveillance of colorectal polyps.MethodsWe collected information on 48 variables from hospital colonoscopy records. Using DILEMMA Solutions Platform © (https://www.dilemasolution.com) we designed a prototype K-CDSS (PoliCare CDSS), to provide tailored recommendations by combining patients data and current guidelines recommendations. The accuracy of rules was verified using four scenarios (normal colonoscopy, lesions different than polyps, non-advanced adenomas and advanced adenomas). We studied the degree of agreement between the clinical assessments made by expert doctors and nurses equipped with PoliCare CDSS. Two experts confirmed a correlation between guidelines and PoliCare recommendations.Results56 consecutive endoscopy cases from colorectal screening program were included (62.8 years; range 53-71). Colonoscopy results were: absence of colon lesions (n = 7, 12.5%), lesions in the colon that are not polyps (n = 3, 5.4%) and resected colonic polyps (n = 46, 82.1%; 100% R0 resection). Patients with resected polyps presented non-advanced adenoma (n = 21, 45.6%) or advanced lesions (n = 25, 54.4%). There were no differences in erroneous orders with PoliCare CDSS (Kappa value 1.0).ConclusionsPoliCare CDSS can easily be integrated into the workflow for improving the overall efficiency and better adherence to evidence-based guidelines.     

Rural–urban differences in the long-term risk of colorectal cancer after adenoma removal: A population-based study

BackgroundWe investigated the impact of municipality of residence on colonoscopic surveillance and colorectal cancer risk after adenoma resection in a French well-defined administrative area.MethodsThis registry-based study included all patients residing in Côte d’Or (n = 5769) first diagnosed with colorectal adenomas between January 1, 1990, and December 31, 1999. Information about colonoscopic surveillance and colorectal cancer incidence was collected until December 31, 2003.ResultsA rural place of residence reduced the probability of colonoscopic surveillance in men [HR = 0.89 (95%CI: 0.79–0.99), p = 0.041] and in patients without family history of colorectal cancer [HR = 0.91(0.82–0.99), p = 0.044]. After a median follow-up of 7.7 years, 87 patients developed invasive colorectal cancer. After advanced adenoma removal, the standardized incidence ratio for colorectal cancer was 3.03 (95%CI: 1.92–4.54) for rural patients and 1.87 (95%CI: 1.26–2.66) for urban patients compared with the general population. The risk of colorectal cancer was higher in rural patients than in urban ones only after removal of the initial advanced adenoma [HR = 1.73 (95%CI: 1.01–3.00, p = 0.048)]. Further adjustment for surveillance colonoscopy, physician location, and other confounders had little impact on these results.ConclusionThe increased risk of subsequent colorectal cancer after advanced adenoma removal in French rural patients was not explained by a lower rate of colonoscopic surveillance. The role of socio-economic and environmental factors requires further exploration.     

Sixty- versus thirty-seconds papillary balloon dilation after sphincterotomy for the treatment of large bile duct stones: A randomized controlled trial

BackgroundEndoscopic biliary sphincterotomy followed by endoscopic papillary balloon dilation is a promising method for large stones. However, there are no data on the optimal duration of papillary balloon dilation after a biliary sphincterotomy.AimsTo compare the effectiveness and complications of the endoscopic papillary balloon dilation for 60 s versus 30 s after endoscopic biliary sphincterotomy.MethodsA total of 124 patients with bile duct stones, submitted for endoscopic biliary sphincterotomy plus endoscopic papillary balloon dilation, were prospectively randomized to either the 60-s dilation group (G60, n = 60) or the 30-s dilation group (G30, n = 64).ResultsThe complete removal of bile duct stones was similar: group G30, 55/64 (86%) versus group G60, 51/60 (85%); p = 0.9. The rates of post-endoscopic retrograde cholangio-pancreatography pancreatitis were also similar: 2 (3.1%) in group G30 versus 2 (3.3%) in group G60, p = 0.9. Post-procedural bleeding occurred in 2 cases (3.1%) in group G30 versus 4 (6.6%) in group G60, (p = 0.17). Two perforations of moderate severity were observed, one in each group.Conclusions30-s papillary balloon dilation, performed after endoscopic biliary sphincterotomy for the management of bile duct stones, was equally effective to the 60-s papillary balloon dilation.     

Impacto de la colonoscopia intraoperatoria en la detección y prevención de la fuga de la anastomosis colorrectal por cáncer de recto

Introduction and aimThe value of leakage testing during colorectal resections to identify anastomotic leaks or bleeding has not been established. Our aim was to compare the impact of intraoperative colonoscopy (IOC) versus insufflation with a syringe, as leakage testing in lower anterior resection for rectal cancer, with respect to the incidence of postoperative leakage (PL).Materials and methodsA retrospective study utilizing a prospective database of 426 patients with rectal cancer that underwent elective lower anterior resection, within the time frame of January 2015 and December 2019, was conducted. The anastomotic leak test was chosen by the surgeon. The incidence of PL was compared between patients that underwent IOC and those that had the syringe leak test, utilizing the logistic regression analysis. Propensity score matching was included.ResultsThere were no significant differences in the clinical characteristics or morbidity and mortality rates between the 2 groups. Four patients were excluded, leaving a patient total of 422. Seventy patients with IOC were compared with 352 that had the syringe leak test. The incidence of PL was 5.7% in the IOC group and 12.2% in the control group (P = .001). After propensity score matching (n = 221), balancing the characteristics between the groups, the incidence of PL was 5.7% in the IOC group and 13.9% in the syringe leak test group (P = .001).ConclusionIOC was shown to be a safe method for evaluating the integrity of colorectal anastomosis and was associated with a higher percentage of protective stoma use, appearing to reduce the risk for PL.