ORCID Profile
0000-0001-9116-6054
Current Organisations
University of Adelaide
,
Gawler Health Service & Calvary Central Districts Hospitals, SA
,
Northern Adelaide Local Health Network
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Publisher: Elsevier BV
Date: 04-2014
DOI: 10.1016/J.CGH.2013.09.049
Abstract: Wide-field endoscopic mucosal resection (WF-EMR) of large sessile colonic polyps is a safe and cost-effective outpatient treatment. Bleeding is the main complication. Few studies have examined risk factors for bleeding during the procedure (intraprocedural bleeding [IPB]) or after it (clinically significant post-endoscopic bleeding [CSPEB]). We investigated factors associated with IPB and CSPEB in a large prospective study. We analyzed data from WF-EMRs of sessile colorectal polyps ≥ 20 mm in size (mean size, 35.5 mm), which were performed on 1172 patients (mean age, 67.8 years) from June 2008-March 2013 at 7 tertiary hospitals as part of the Australian Colonic Endoscopic Resection Study. Data were collected on characteristics of patients and lesions, along with outcomes of procedures and clinical and histologic analyses. Independent predictors of IPB and CSPEB were identified by multiple logistic regression analysis. Of the patients studied, 133 (11.3%) had IPB. Independent predictors included increasing lesion size (odds ratio, 1.24/10 mm P < .001), Paris endoscopic classification of 0-IIa + Is (odds ratio, 2.12 P = .004), tubulovillous or villous histology (odds ratio, 1.84 P = .007), and study institutions that performed the procedure on fewer than 75 patients (odds ratio, 3.78 P < .001). All IPB was successfully controlled endoscopically. IPB prolonged procedures and was associated with early recurrence (relative risk, 1.68 P = .011). Seventy-three patients (6.2%) had CSPEB. On multivariable analysis, CSPEB was associated with proximal colon location (odds ratio, 3.72 P < .001), use of an electrosurgical current not controlled by a microprocessor (odds ratio, 2.03 P = .038), and IPB (odds ratio, 2.16 P = .016). Lesion size and comorbidities did not predict CSPEB. In a prospective study of patients undergoing WF-EMR of large sessile colonic polyps, IPB is associated with larger lesions, lesion histology, and Paris endoscopic classification of type 0-IIa + Is. IPB prolongs the duration of the procedure, is a marker for recurrence, and is associated with CSPEB. CSPEB occurs most frequently in the proximal colon and less when current is controlled by a microprocessor.
Publisher: Georg Thieme Verlag KG
Date: 31-05-2017
Publisher: Elsevier BV
Date: 05-2018
DOI: 10.1016/J.GIE.2017.12.018
Abstract: EMR of sessile periappendiceal laterally spreading lesions (PA-LSLs) is technically demanding because of poor endoscopic access to the appendiceal lumen and the thin colonic wall at the base of the cecum. We aimed to assess the feasibility and safety of EMR for PA-LSLs. Consecutive LSLs ≥20 mm and PA-LSLs ≥10 mm detected at 3 academic endoscopy centers from September 2008 until January 2017 were eligible. Prospective patient, procedural, and lesion data were collected. PA-LSLs were compared with LSLs in other colonic locations. Thirty-eight PA-LSLs were compared with 1721 LSLs. Referral for surgery without an attempt at EMR was more likely with PA-LSLs (28.9% vs 5.1%, P < .001), and those that involved a greater percentage of the appendiceal orifice (AO) were less likely to be attempted (P = .038). Most PA-LSLs (10/11) were not attempted because of deep extension into the appendiceal lumen 2 of 11 of these surgical specimens contained invasive cancer. Once attempted, complete clearance of visible adenoma (92.6% PA-LSLs vs 97.6% LSLs, P = .14), adverse events, and rates of adenoma recurrence did not vary significantly between PA-LSLs and LSLs. All 7 patients with prior appendicectomy achieved complete adenoma clearance. There were no cases of post-EMR appendicitis. Twenty of 22 PA-LSLs (91%) eligible for surveillance avoided surgery to longest follow-up. EMR is a safe, effective, and durable treatment for PA-LSLs when specific criteria are fulfilled. If the distal margin of the PA-LSL within the AO cannot be visualized or if more than 50% of the circumference of the orifice is involved, surgery should be considered. (Clinical trial registration number: NTC01368289.).
Publisher: BMJ
Date: 12-11-2018
DOI: 10.1136/GUTJNL-2018-317111
Abstract: This is a consensus developed by a group of expert endoscopists aiming to standardise the preparation, process and endoscopic procedural steps for diagnosis of early upper gastrointestinal (GI) cancers. The Delphi method was used to develop consensus statements through identification of clinical questions on diagnostic endoscopy. Three consensus meetings were conducted to consolidate the statements and voting. We conducted a systematic literature search on evidence for each statement. The statements were presented in the second consensus meeting and revised according to comments. The final voting was conducted at the third consensus meeting on the level of evidence and agreement. Risk stratification should be conducted before endoscopy and high risk endoscopic findings should raise an index of suspicion. The presence of premalignant mucosal changes should be documented and use of sedation is recommended to enhance detection of superficial upper GI neoplasms. The use of antispasmodics and mucolytics enhanced visualisation of the upper GI tract, and systematic endoscopic mapping should be conducted to improve detection. Sufficient examination time and structured training on diagnosis improves detection. Image enhanced endoscopy in addition to white light imaging improves detection of superficial upper GI cancer. Magnifying endoscopy with narrow-band imaging is recommended for characterisation of upper GI superficial neoplasms. Endoscopic characterisation can avoid unnecessary biopsy. This consensus provides guidance for the performance of endoscopic diagnosis and characterisation for early gastric and oesophageal neoplasia based on the evidence. This will enhance the quality of endoscopic diagnosis and improve detection of early upper GI cancers.
Publisher: Baishideng Publishing Group Inc.
Date: 2009
Publisher: Wiley
Date: 25-04-2013
DOI: 10.1111/DEN.12093
Abstract: The incidence of Barrett's adenocarcinoma has increased dramatically over the past few decades in most Western countries. While Barrett's esophagus is uncommon and adenocarcinoma is still rare in Asian populations, several Asian studies have indicated that the prevalence of esophageal adenocarcinoma is gradually increasing. Therefore, in order to determine the best way to treat superficial Barrett's adenocarcinoma, 12 expert endoscopists and a pathologist from the Asia-Pacific region conducted a session entitled 'The current status of endoscopic diagnosis and treatment of superficial Barrett's adenocarcinoma'. After three keynote lectures, three Japanese panels presented cases of superficial Barrett's adenocarcinomas diagnosed by image-enhanced endoscopy (IEE). We then confirmed the results of a questionnaire on the diagnosis and treatment of superficial Barrett's adenocarcinomas. Finally, a panel introduced an Asia-Pacific international study on simplified narrow-band imaging (NBI) classification of Barrett's esophagus and neoplasias. After a discussion, we proposed consensus statements on endoscopic diagnosis and treatment of superficial Barrett's adenocarcinoma as follows. Representative characteristics by conventional white light endoscopy are a reddish area or a lesion located on the anterior to right side wall. IEE may be useful for characterizing the tumor and diagnosing lateral tumor extension. Superficial Barrett's adenocarcinoma adjacent to the squamocolumnar junction is sometimes associated with subsquamous tumor extension. IEE may be useful to detect the subsquamous tumor extension especially when using NBI or an acetic acid-spraying method. Endoscopic mucosal resection or endoscopic submucosal dissection for mucosal carcinomas could provide excellent prognosis.
Publisher: Elsevier BV
Date: 07-2009
DOI: 10.1016/J.GIE.2008.10.026
Abstract: Autofluorescence imaging is a novel imaging technique that may improve the detection of early neoplasia in Barrett's esophagus. Autofluorescence imaging is, however, associated with a 40% to 81% false-positive rate. Our purpose was to identify endoscopic features that may predict the presence of early neoplasia in autofluorescence-positive areas. Descriptive and prospective cohort study. Tertiary referral centers for the detection and treatment of early Barrett's neoplasia. Patients undergoing autofluorescence endoscopy. High-quality images with autofluorescence imaging and white-light endoscopy were obtained with corresponding histologic study. A systematic image evaluation process was performed, including an unblinded orientation phase (10 areas), a blinded derivation phase, and a blinded validation phase by 5 international experts in autofluorescence imaging (80 areas). Subsequently the identified features were validated in a prospective pilot study. Association between endoscopic features and presence of early neoplasia in autofluorescence-positive areas. Autofluorescence intensity, proximity of gastric folds <1 cm, and different appearance on white-light endoscopy were independently associated with early neoplasia in autofluorescence-positive areas on multivariate analysis. The kappa values for interobserver agreement of these factors were moderate, ranging between 0.49 to 0.56. The association with autofluorescence intensity and different appearance on white-light endoscopy was confirmed in a prospective pilot study. Selected set of images from a high-risk population (tertiary referral center). We found specific endoscopic features that were associated with early neoplasia in autofluorescence-positive areas. These findings can be used in future prospective studies to improve the accuracy of autofluorescence imaging without performing magnification endoscopy for detailed inspection of suspicious areas.
Publisher: Baishideng Publishing Group Inc.
Date: 16-09-2018
Publisher: Baishideng Publishing Group Inc.
Date: 2010
Publisher: Baishideng Publishing Group Inc.
Date: 15-04-2021
Publisher: Elsevier BV
Date: 03-2016
Publisher: BMJ
Date: 02-03-2015
DOI: 10.1136/GUTJNL-2014-308603
Abstract: The serrated neoplasia pathway accounts for up to 30% of all sporadic colorectal cancers (CRCs). Sessile serrated adenomas olyps (SSA/Ps) with cytological dysplasia (SSA/P-D) are a high-risk serrated CRC precursor with little existing data. We aimed to describe the clinical and endoscopic predictors of SSA/P-D and high grade dysplasia (HGD) or cancer. Prospective multicentre data of SSA/Ps ≥20 mm referred for treatment by endoscopic mucosal resection (September 2008-July 2013) were analysed. Imaging and lesion assessment was standardised. Histological findings were correlated with clinical and endoscopic findings. 268 SSA/Ps were found in 207/1546 patients (13.4%). SSA/P-D comprised 32.4% of SSA/Ps ≥20 mm. Cancer occurred in 3.9%. On multivariable analysis, SSA/P-D was associated with increasing age (OR=1.69 per decade 95% CI (1.19 to 2.40), p0.004) and increasing lesion size (OR=1.90 per 10 mm 95% CI (1.30 to 2.78), p0.001), an 'adenomatous' pit pattern (Kudo III, IV or V) (OR=3.98 95% CI (1.94 to 8.15), p<0.001) and any 0-Is component within a SSA/P (OR=3.10 95% CI (1.19 to 8.12) p0.021). Conventional type dysplasia was more likely to exhibit an adenomatous pit pattern than serrated dysplasia. HGD or cancer was present in 7.2% and on multivariable analysis, was associated with increasing age (OR=2.0 per decade 95% CI 1.13 to 3.56) p0.017) and any Paris 0-Is component (OR=10.2 95% CI 3.18 to 32.4, p<0.001). Simple assessment tools allow endoscopists to predict SSA/P-D or HGD/cancer in SSA/Ps ≥20 mm. Correct prediction is limited by failure to recognise SSA/P-D which may mimic conventional adenoma. Understanding the concept of SSA/P-D and the pitfalls of SSA/P assessment may improve detection, recognition and resection and potentially reduce interval cancer. NCT01368289.
Publisher: Elsevier BV
Date: 11-2021
Publisher: Wiley
Date: 08-01-2019
DOI: 10.1111/JGH.14566
Abstract: Adenoma detection rate (ADR) is an important quality metric in colonoscopy. However, there is conflicting evidence around factors that influence ADR. This study aims to investigate the effect of time of day and endoscopist background on ADR and sessile serrated adenoma olyp detection rate (SSA/P-DR) for screening colonoscopies. Consecutive patients undergoing colonoscopy in 2016 were retrospectively evaluated. Primary outcome was the effect of time of day and endoscopist specialty on screening ADR. Secondary outcomes included evaluation of the same factors on SSA/P-DR and other metrics and collinearity of ADR and SSA/P-DR. Linear regression models were used for association between ADR, time of day, and endoscopist background. Bowel preparation, endoscopist, session, patient age, and gender were adjusted for. Linear regression model was also used for comparing ADR and SSA/P-DR. Chi-square was used for difference of proportions. Two thousand six hundred fifty-seven colonoscopies, of which 558 were screening colonoscopies, were performed. The adjusted mean ADR (screening) was 36.8% in the morning compared with 30.5% in the afternoon (P < 0.0001) and was 36.8% for gastroenterologists compared with 30.4% for surgeons (P < 0.0001). For every 1-h delay in commencing the procedure, there was a reduction in mean ADR by 3.4%. Using a linear regression model, a statistically significant positive association was found between ADR and SSA/P-DR (P < 0.0001). Morning and afternoon sessions and gastroenterologists and surgeons achieved the minimum standards recommended for ADR. Afternoon lists and surgeons were associated with a lower ADR compared with morning and gastroenterologists, respectively. Additionally, SSA/P-DR showed collinearity with ADR.
Publisher: Wiley
Date: 05-05-2021
DOI: 10.1111/JGH.15577
Abstract: Endoscopic surveillance for dysplasia in Barrett's esophagus (BE) with random biopsies is the primary diagnostic tool for monitoring clinical progression into esophageal adenocarcinoma. As an alternative, narrow‐band imaging (NBI) endoscopy offers targeted biopsies that can improve dysplasia detection. This study aimed to evaluate NBI‐guided targeted biopsies' diagnostic accuracy for detecting dysplasia in patients undergoing endoscopic BE surveillance compared with the widely used Seattle protocol. Cochrane DTA Register, MEDLINE/PubMed, EMBASE, OpenGrey, and bibliographies of identified papers were searched until 2018. Two independent investigators resolved discrepancies by consensus, study selection, data extraction, and quality assessment. Data on sensitivity, specificity, and predictive values were pooled and analyzed using a random‐effects model. Of 9528 identified articles, six studies comprising 493 participants were eligible for quantitative synthesis. NBI‐targeted biopsy showed high diagnostic accuracy in detection of dysplasia in BE with a sensitivity of 76% (95% confidence interval [CI]: 0.61–0.91), specificity of 99% (95% CI: 0.99–1.00), positive predictive value of 97% (95% CI: 0.96–0.99), and negative predictive value of 84% (95% CI: 0.69–0.99) for detection of all grades of dysplasia. The receiver‐operating characteristic curve for NBI model performance was 0.8550 for detecting all dysplasia. Narrow‐band imaging‐guided biopsy demonstrated high diagnostic accuracy and might constitute a valid substitute for random biopsies during endoscopic surveillance for dysplasia in BE.
Publisher: Wiley
Date: 04-2015
DOI: 10.1111/DEN.12419
Abstract: Colorectal cancer (CRC) is a global epidemic predominantly affecting Western countries. It is the second leading cause of cancer-related deaths in Australia with one in 12 Australians affected by this condition by the age of 85 years. Appropriate preventive measures by screening followed by colonoscopy can detect cancer and precancerous lesions, which are potentially curable. The National Bowel Cancer Screening Program (NBCSP) is a national screening program implemented by the Australian Government aimed at reducing morbidity and mortality from bowel cancer by actively recruiting and screening the target population. The long-term goal of the program is to include the at-risk population (50-74 years of age) in a biennial screening program. Newer technologies could have a potential role in screening programs by enhancing adenoma detection rates. However, until more evidence is available, improving screening uptake and bowel preparation strategies are the prime focus in reducing CRC-related morbidity and mortality.
Publisher: AME Publishing Company
Date: 07-2020
Publisher: Elsevier BV
Date: 05-2019
DOI: 10.1016/J.GIE.2019.08.036
Abstract: Surveillance post-endoscopic resection (ER) currently warrants biopsy s les from the resection site scar in most cases, although clinical practice is variable. A classification with standard criteria for scars has not yet been established. We aimed to create and validate a novel classification for post-ER scars by using specific criteria based on advanced imaging. Key endoscopic features for scars with and without recurrence were (1) dark brown color, elongated/branched pit pattern, and dense capillary pattern and (2) whitish, pale appearance, round/slightly large pits, and irregular sparse vessels. Scars were first assessed with high-definition white-light endoscopy (HD-WLE) followed by interrogation with narrow-band imaging (NBI). Scars with at least 2 concordant characteristics were diagnosed with "high confidence" for NBI for scar (NBI-SCAR) classification. The final endoscopic predictions were correlated with histopathology. The primary outcome was the difference in sensitivity between NBI-SCAR and HD-WLE predictions. Secondary outcomes included the validation of our findings in 6 different endoscopy settings (Australia, United States, Japan, Brazil, Singapore, and Malaysia). The validation took place in 2 sessions separated by 2 to 3 weeks, each with 10 one-minute videos of post-ER scars on underwater NBI with dual focus. Inter-rater and intrarater reliability were calculated with Fleiss' free-marginal kappa and Bennett et al. S score, respectively. One hundred scars from 82 patients were included. Ninety-five scars were accurately predicted with high confidence by NBI-SCAR in the exploratory phase. NBI-SCAR sensitivity was significantly higher compared with HD-WLE (100% vs 73.7%, P < .05). In the validation phase, similar results were found for endoscopists who routinely perform colonoscopies and use NBI (sensitivity of 96.4%). The inter-rater and intrarater reliability throughout all centers were, respectively, substantial (κ = .61) and moderate (average S = .52) for this subset. NBI-SCAR has a high sensitivity and negative predictive value for excluding recurrence for endoscopists experienced in colonoscopy and NBI. In this setting, this approach may help to accurately evaluate or resect scars and potentially mitigate the burden of unnecessary biopsy s les.
Publisher: Baishideng Publishing Group Inc.
Date: 2013
Publisher: Elsevier BV
Date: 05-2020
Publisher: Elsevier BV
Date: 10-2014
DOI: 10.1016/J.GIE.2014.04.015
Abstract: EMR of advanced mucosal neoplasia (AMN) (ie, sessile or laterally spreading lesions of ≥20 mm) of the colon has become an increasingly popular alternative to surgical resection. However, data regarding safety and mortality of EMR in comparison to surgery are limited. To compare actual endoscopic with predicted surgical mortality. Prospective, observational, multicenter cohort study. Academic, high-volume, tertiary-care referral center. Consecutive patients referred for EMR. To predict hypothetical surgical mortality, the Association of Coloproctology of Great Britain and Ireland score, composed of physiological and surgical components, was calculated for each patient. Predicted surgical mortality was then compared with actual outcomes of EMR. The results were validated by an unselected subcohort by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity. Among 1050 patients with AMN treated by EMR, including patients with a predicted mortality rate of greater than 5% (13.8% of cohort), no deaths occurred within 30 days after the procedure. The predicted surgical mortality rate was 3.3% with the Association of Coloproctology of Great Britain and Ireland score (P < .0001). This suggests a significant advantage of EMR over surgery. The results were validated by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity in 390 patients predicting a surgical mortality rate of 3.2% (P = .0003). Nonrandomized study. In this large multicenter study of EMR for colonic AMN, the predicted surgical mortality rate was significantly higher than the actual endoscopic mortality rate. Given that endoscopic therapy is less morbid and less expensive than surgery and can be performed as an outpatient treatment, it should be considered as the first line of treatment for most patients with these lesions.
Publisher: Georg Thieme Verlag KG
Date: 02-2017
Abstract: Background and study aims Physician-directed nurse-administered balanced propofol sedation (PhD NAPS) in patients undergoing endoscopy and/or colonoscopy is being increasingly utilized worldwide. However, this method of sedation is not universally employed in Australian hospitals due to concerns surrounding its safety. The aim of this study was to assess the safety of PhD NAPS in low-risk patients undergoing endoscopy and/or colonoscopy. Patients and methods This study was conducted at a single tertiary teaching hospital in Adelaide, Australia. It was a prospective study involving 1000 patients with an ASA score of 1 – 3 presenting with any indication for endoscopy, colonoscopy or both. A total of 981 patients (451 male) with a mean age of 53 years (range: 16 – 87) were recruited from January 2010 to October 2012. 440 endoscopies, 420 colonoscopies, and 121 combined procedures were performed. The intra-procedural adverse events (AEs) were recorded. Results There were no major intra-procedural adverse events. Minor AEs occurred in 6.42 % of patients, and resolved spontaneously or with intravenous fluid boluses in all cases. Conclusion PhD NAPS is safe when the proceduralist and nursing staff are adequately trained and strict patient selection criteria are used.
Publisher: Georg Thieme Verlag KG
Date: 26-04-2018
DOI: 10.1055/A-0602-1390
Publisher: Medknow
Date: 10-2019
Publisher: The Editorial Office of Gut and Liver
Date: 30-12-2007
Publisher: Elsevier BV
Date: 09-2014
DOI: 10.1016/J.CGH.2014.01.026
Abstract: Bleeding is the main complication of wide-field endoscopic mucosal resection (WF-EMR) for large colonic lesions. Few studies have examined bleeding outcomes after WF-EMR, and there are no evidence-based guidelines for management of bleeding in this group. We analyzed outcomes of patients with clinically significant post-EMR bleeding (CSPEB) and present a management algorithm based on our findings. In a prospective study, we collected data from WF-EMR of sessile colorectal polyps 20 mm or larger from 1039 patients who participated in the Australian Colonic Endoscopic resection multicenter study from July 2008 through May 2012. Data included patient and lesion characteristics and procedural, clinical, and histologic outcomes. Patients participated in a structured telephone interview 14 days after the procedure independent predictors of a moderate or severe outcome by American Society of Gastrointestinal Endoscopists criteria, or any intervention for hemostasis, were identified. Sixty-two patients had CSPEB (6.0%) 34 were managed conservatively (55%) and 27 underwent colonoscopy (44%). One patient had primary embolization. Endoscopic therapy was applied in 21 cases 14 had active bleeding. Two of the conservatively managed cases underwent colonoscopy for rebleeding after discharge. On multivariable analysis, moderate or severe bleeding events were associated with hemodynamic instability (odds ratio, 12.3 P = .046) and low level of hemoglobin at presentation (odds ratio, 0.50 per 1.0 g/dL P = .005). Intervention for hemostasis was associated with hourly or more frequent hematochezia (odds ratio, 36.7 P = .001), American Society of Anesthesiologists grade 2 or higher (odds ratio, 20.1 P < .001), and transfusion (odds ratio, 18.7 P = .003). Based on a multicenter prospective study, CSPEB resolves spontaneously in 55% of patients. We developed a risk factor-based algorithm that might assist physicians in the management of bleeding. Patients responding to initial resuscitation can be observed, with a lower threshold for intervention in those with the identified risk factors.
Publisher: BMJ
Date: 07-2014
DOI: 10.1136/GUTJNL-2013-305516
Abstract: Wide-field endoscopic mucosal resection (WF-EMR) is an alternative to surgery for treatment of advanced colonic mucosal neoplasia up to 120 mm in size, but has been criticised for its potentially high recurrence rates. We aimed to quantify recurrence at 4 months (early) and 16 months (late) following successful WF-EMR and identify its risk factors and clinical significance. Ongoing multicentre, prospective, intention-to-treat analysis of sessile or laterally spreading colonic lesions ≥20 mm in size referred for WF-EMR to seven academic endoscopy units. Surveillance colonoscopy (SC) was performed 4 months (SC1) and 16 months (SC2) after WF-EMR, with photographic documentation and biopsy of the scar. 1134 consecutive patients were enrolled when 1000 successful EMRs were achieved, of whom 799 have undergone SC1. 670 were normal. Early recurrent/residual adenoma was present in 128 (16.0%, 95% CI 13.6% to 18.7%). One case was unknown. The recurrent/residual adenoma was diminutive in 71.7% of cases. On multivariable analysis, risk factors were lesion size >40 mm, use of argon plasma coagulation and intraprocedural bleeding. Of 670 with normal SC1, 426 have undergone SC2, with late recurrence present in 17 cases (4.0%, 95% CI 2.4% to 6.2%). Overall, recurrent/residual adenoma was successfully treated endoscopically in 135 of 145 cases (93.1%, 95% CI 88.1% to 96.4%). If the initial EMR was deemed successful and did not contain submucosal invasion requiring surgery, 98.1% (95% CI 96.6% to 99.0%) were adenoma-free and had avoided surgery at 16 months following EMR. Following colonic WF-EMR, early recurrent/residual adenoma occurs in 16%, and is usually unifocal and diminutive. Risk factors were identified. Late recurrence occurs in 4%. Overall, recurrence was managed endoscopically in 93% of cases. Recurrence is not a significant clinical problem following WF-EMR, as with strict colonoscopic surveillance, it can be managed endoscopically with high success rates. NCT01368289.
Publisher: The Korean Society of Gastrointestinal Endoscopy
Date: 2011
Publisher: Informa UK Limited
Date: 15-11-0006
DOI: 10.1586/17474124.2015.983080
Abstract: Barrett's esophagus is the only known precursor that predisposes patients to the development of esophageal adenocarcinoma. The current recommended surveillance method is targeted biopsies of any abnormalities followed by random four-quadrant biopsies every 2 cm using standard white light endoscopy. Compliance with this and s ling error are two of the biggest problems. Several novel imaging technologies have been developed to aid the diagnosis of early neoplasia in Barrett's esophagus. There are emerging data that some of these new modalities can increase the yield of detecting dysplasia. This review will discuss some of the present available techniques and technologies including chromoendoscopy, narrow-band imaging, autofluorescence imaging, optical coherence tomography, confocal endomicroscopy and endocytoscopy. Based on the current evidence, these imaging modalities appear to be promising as adjunctive tools to white light endoscopy. A few of them, nevertheless, remain experimental due to expense, lack of expertise, generalizability as well as reproducibility of results.
Publisher: BMJ
Date: 24-04-2018
DOI: 10.1136/GUTJNL-2018-316276
Abstract: Non-variceal upper gastrointestinal bleeding remains an important emergency condition, leading to significant morbidity and mortality. As endoscopic therapy is the ’gold standard' of management, treatment of these patients can be considered in three stages: pre-endoscopic treatment, endoscopic haemostasis and post-endoscopic management. Since publication of the Asia-Pacific consensus on non-variceal upper gastrointestinal bleeding (NVUGIB) 7 years ago, there have been significant advancements in the clinical management of patients in all three stages. These include pre-endoscopy risk stratification scores, blood and platelet transfusion, use of proton pump inhibitors during endoscopy new haemostasis techniques (haemostatic powder spray and over-the-scope clips) and post-endoscopy management by second-look endoscopy and medication strategies. Emerging techniques, including capsule endoscopy and Doppler endoscopic probe in assessing adequacy of endoscopic therapy, and the pre-emptive use of angiographic embolisation, are attracting new attention. An emerging problem is the increasing use of dual antiplatelet agents and direct oral anticoagulants in patients with cardiac and cerebrovascular diseases. Guidelines on the discontinuation and then resumption of these agents in patients presenting with NVUGIB are very much needed. The Asia-Pacific Working Group examined recent evidence and recommends practical management guidelines in this updated consensus statement.
Publisher: Wiley
Date: 15-01-2020
DOI: 10.1002/JGH3.12298
Publisher: Georg Thieme Verlag KG
Date: 24-06-2015
Publisher: Georg Thieme Verlag KG
Date: 25-01-2018
Abstract: Background The SMSA (size, morphology, site, access) polyp scoring system is a method of stratifying the difficulty of polypectomy through assessment of four domains. The aim of this study was to evaluate the ability of SMSA to predict critical outcomes of endoscopic mucosal resection (EMR). Methods We retrospectively applied SMSA to a prospectively collected multicenter database of large colonic laterally spreading lesions (LSLs) ≥ 20 mm referred for EMR. Standard inject-and-resect EMR procedures were performed. The primary end points were correlation of SMSA level with technical success, adverse events, and endoscopic recurrence. Results 2675 lesions in 2675 patients (52.6 % male) underwent EMR. Failed single-session EMR occurred in 124 LSLs (4.6 %) and was predicted by the SMSA score (P 0.001). Intraprocedural and clinically significant postendoscopic bleeding was significantly less common for SMSA 2 LSLs (odds ratio [OR] 0.36, P 0.001 and OR 0.23, P 0.01) and SMSA 3 LSLs (OR 0.41, P 0.001 and OR 0.60, P = 0.05) compared with SMSA 4 lesions. Similarly, endoscopic recurrence at first surveillance was less likely among SMSA 2 (OR 0.19, P 0.001) and SMSA 3 (OR 0.33, P 0.001) lesions compared with SMSA 4 lesions. This also extended to second surveillance among SMSA 4 LSLs. Conclusion SMSA is a simple, readily applicable, clinical score that identifies a subgroup of patients who are at increased risk of failed EMR, adverse events, and adenoma recurrence at surveillance colonoscopy. This information may be useful for improving informed consent, planning endoscopy lists, and developing quality control measures for practitioners of EMR, with potential implications for EMR benchmarking and training.
Publisher: Wiley
Date: 05-06-2022
DOI: 10.1111/DEN.14342
Abstract: Endoscopic diagnosis of gastroesophageal junction and Barrett's esophagus is essential for surveillance and early detection of esophageal adenocarcinoma and esophagogastric junction cancer. Despite its small size, the gastroesophageal junction has many inherent problems, including marked differences in diagnostic methods for Barrett's esophagus in international guidelines. To define Barrett's esophagus, gastroesophageal junction location should be clarified. Although gastric folds and palisade vessels are landmarks for identifying this junction, they are sometimes difficult to observe due to air entry or reflux esophagitis. The possibility of diagnosing a malignancy associated with Barrett's esophagus cm, identified using palisade vessels, should be re‐examined. Nontargeted biopsies of Barrett's esophagus are commonly used to detect intestinal metaplasia, dysplasia, and cancer as described in the Seattle protocol. Barrett's esophagus with intestinal metaplasia has a high risk of becoming cancerous. Furthermore, the frequency of cancer in patients with Barrett's esophagus without intestinal metaplasia is high, and the guidelines differ on whether to include the presence of intestinal metaplasia in the diagnosis of Barrett's esophagus. Use of advanced imaging technologies, including narrow‐band imaging with magnifying endoscopy and linked color imaging, is reportedly valid for diagnosing Barrett's esophagus. Furthermore, artificial intelligence has facilitated the diagnosis of Barrett's esophagus through its deep learning and image recognition capabilities. However, it is necessary to first use the endoscopic definition of the gastroesophageal junction, which is common in all countries, and then elucidate the characteristics of Barrett's esophagus in each region, for ex le, length differences in the risk of carcinogenesis with and without intestinal metaplasia.
Publisher: Wiley
Date: 29-03-2019
DOI: 10.1111/DEN.13330
Publisher: Elsevier BV
Date: 03-2014
DOI: 10.1016/J.GIE.2013.07.032
Abstract: Experts can accurately characterize the histology of diminutive polyps with narrow-band imaging (NBI). There are limited data on the performance of non-experts. To assess the impact of a computer-based teaching module on the accuracy of predicting polyp histology with NBI by non-experts (in academics and community practice) by using video clips. Prospective, observational study. Academic and community practice. A total of 15 gastroenterologists participated-5 experts in NBI, 5 non-experts in academic practice, and 5 non-experts in community practice. Participants reviewed a 20-minute, computer-based teaching module outlining the different NBI features for hyperplastic and adenomatous polyps. Performance characteristics in characterizing the histology of diminutive polyps with NBI by using short video clips before (pretest) and after (posttest) reviewing the teaching module. Non-experts in academic practice showed a significant improvement in the sensitivity (54% vs 79% P < .001), accuracy (64% vs 81% P < .001), and proportion of high-confidence diagnoses (49% vs 69% P < .001) in the posttest. Non-experts in community practice had significantly higher sensitivity (58% vs 75% P = .004), specificity (76% vs 90% P = .04), accuracy (64% vs 81% P < .001), and proportion of high-confidence diagnoses (49% vs 72% P < .001) in the posttest. Performance of experts in NBI was significantly better than non-experts in both academic and community practice. Selection bias in selecting good quality videos. Performance not assessed during live colonoscopy. Academic and community gastroenterologists without prior experience in NBI can achieve significant improvements in characterizing diminutive polyp histology after a brief computer-based training. The durability of these results and applicability in everyday practice are uncertain.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 30-07-2021
Publisher: Elsevier BV
Date: 05-2020
DOI: 10.1016/J.GIE.2019.12.025
Abstract: Residual or recurrent adenoma (RRA) is the major limitation of piecemeal EMR (p-EMR) for large colonic laterally spreading lesions (LSLs) ≥20 mm. En bloc EMR (e-EMR) has been shown to achieve low rates of RRA but specific procedural and long-term outcomes are unknown. Our aim was to compare long-term outcomes of size-matched LSLs stratified by whether they were resected e-EMR or p-EMR. Data from a prospective tertiary referral multicenter cohort of large LSLs referred for EMR over a 10-year period were analyzed. Outcomes were compared between sized-matched LSLs (20-25 mm) resected by p-EMR or e-EMR. Five hundred seventy LSLs met the inclusion criteria of which 259 (45.4%) were resected by e-EMR. The risk of major deep mural injury (DMI) was significantly higher in the e-EMR group (3.5% vs 1.0%, P = .05), whereas rates of other intraprocedural adverse events did not differ significantly. Five of 9 (56%) LSLs, with endoscopic features of submucosal invasion (SMI), resected by e-EMR were saved from surgery. RRA at first surveillance was lower in the e-EMR group (2.0% vs 5.7%, P = .04), but this difference was negated at subsequent surveillance. Rates of surgical referral were not significantly different between the groups at either surveillance interval. When comparing e-EMR against p-EMR for lesions ≤25 mm in size of similar morphology in a large prospective multicenter cohort, e-EMR offered no additional advantage for predicted-benign LSLs. However, it was associated with an increased risk of major DMI. Thus, en bloc resection techniques should be reserved for lesions suspicious for invasive disease. (Clinical trial registration number: NCT01368289.).
Publisher: Wiley
Date: 04-12-2013
DOI: 10.1111/DEN.12207
Abstract: With the ever-increasing concern regarding morbidity and mortality associated with diseases of the gastrointestinal tract, the importance of an effective and efficient diagnostic tool cannot be overstated. The standard of care currently is an examination using conventional white light endoscopy. This approach may occasionally overlook areas exhibiting a premalignant change. Numerous image-enhanced modalities have been recently introduced. Narrow band imaging (NBI) appears to be the most prominent of these and perhaps the most commonly used. Thepresent review will focus on some of the newer studies on NBI and its utility in the diagnosis of malignant, pre-malignant and chronic inflammatory conditions of the upper gastrointestinal tract.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2015
Publisher: Wiley
Date: 31-10-2013
DOI: 10.1111/ANS.12356
Publisher: Wiley
Date: 29-04-2011
DOI: 10.1111/J.1443-1661.2011.01119.X
Abstract: In Asian countries, squamous cell carcinoma is the most common type of esophageal cancer, and the incidence of gastric cancer remains have plateaued. To synthesize current information and to illustrate its clinical benefit of narrow band imaging (NBI) for diagnosis of superficial esophageal squamous carcinoma (SESCC) and early gastric cancer (EGC), a consensus conference was held by a panel of nine experts from Asian-Pacific countries. The expert's agreement suggested importance of interpretation of both vascular architecture and surface structure of the lesions and proper processor settings for endoscopic images. Zoom endoscopy was not regarded as absolutely necessary for detection of SESCC, but magnifying observation provided valuable information for characterization of detected lesions in the esophagus and the stomach. In general, NBI is useful for detection and characterization of SESCC, whereas it is beneficial mainly for characterization of EGC. Chromoendoscopy was found to be still worthwhile in certain situations, such as determination of the extent of SESCC by Lugol's staining, or detection and delineation of EGC by indigo carmine. NBI could replace chromoendoscopy in routine examination because it is easy to use and adds much information to conventional WLI, but it cannot eliminate chromoendoscopy when we make a final diagnosis for treatment decision-making. Consequently, the benefit of NBI or magnifying NBI is specific for the organ and the purpose of the examination, thus optimum indication and usage should be understood for maximum clinical benefit.
Publisher: Elsevier BV
Date: 08-2015
DOI: 10.1016/J.BPG.2015.06.004
Abstract: Barrett's esophagus is a known precursor for esophageal adenocarcinoma. Early detection of dysplasia provides a window of opportunity for curative intervention. Several image-enhanced technologies have been developed to improve visualization of neoplasia. These however have not been found to be superior to the standard four quadrant random biopsy protocol. Patients are risk-stratified based on the degree of dysplasia found on biopsies and undergo either surveillance or treatment. Endoscopic therapy has become the mainstay of treatment for early neoplasia.
Publisher: Informa UK Limited
Date: 2009
DOI: 10.1080/00365520802400818
Abstract: To evaluate whether there is any appreciable difference in imaging characteristics between high-resolution magnification white-light endoscopy (WLE-Z) and narrow-band imaging (NBI-Z) in Barrett's oesophagus (BE) and if this translates into superior prediction of histology. This was a prospective single-centre study involving 21 patients (75 areas, corresponding NBI-Z and WLE-Z images) with BE. Mucosal patterns (pit pattern and microvascular morphology) were evaluated for their image quality on a visual analogue scale (VAS) of 1-10 by five expert endoscopists. The endoscopists then predicted mucosal morphology based on four subtypes which can be visualized in BE. Type A: round pits, regular microvasculature type B: villous/ridge pits, regular microvasculature type C: absent pits, regular microvasculature type D: distorted pits, irregular microvasculature. The sensitivity (Sn), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV) and accuracy (Acc) were then compared with the final histopathological analysis and the interobserver variability calculated. The overall pit and microvasculature quality was significantly higher for NBI-Z, pit: NBI-Z=6, WLE-Z=4.5, p < 0.001 microvasculature: NBI-Z=7.3, WLE-Z=4.9, p < 0.001. This translated into a superior prediction of histology (Sn: NBI-Z: 88.9, WLE-Z: 71.9, p < 0.001). For the prediction of dysplasia, NBI-Z was superior to WLE-Z (chi(2)=10.3, p < 0.05). The overall kappa agreement among the five endoscopists for NBI-Z and WLE-Z, respectively, was 0.59 and 0.31 (p < 0.001). NBI-Z is superior to WLE-Z in the prediction of histology in BE, with good reproducibility. This novel imaging modality could be an important tool for surveillance of patients with BE.
Publisher: Informa UK Limited
Date: 2008
Publisher: Georg Thieme Verlag KG
Date: 09-11-2020
DOI: 10.1055/A-1306-7590
Abstract: Background Artificial intelligence (AI) research in colonoscopy is progressing rapidly but widespread clinical implementation is not yet a reality. We aimed to identify the top implementation research priorities. Methods An established modified Delphi approach for research priority setting was used. Fifteen international experts, including endoscopists and translational computer scientists/engineers, from nine countries participated in an online survey over 9 months. Questions related to AI implementation in colonoscopy were generated as a long-list in the first round, and then scored in two subsequent rounds to identify the top 10 research questions. Results The top 10 ranked questions were categorized into five themes. Theme 1: clinical trial design/end points (4 questions), related to optimum trial designs for polyp detection and characterization, determining the optimal end points for evaluation of AI, and demonstrating impact on interval cancer rates. Theme 2: technological developments (3 questions), including improving detection of more challenging and advanced lesions, reduction of false-positive rates, and minimizing latency. Theme 3: clinical adoption/integration (1 question), concerning the effective combination of detection and characterization into one workflow. Theme 4: data access/annotation (1 question), concerning more efficient or automated data annotation methods to reduce the burden on human experts. Theme 5: regulatory approval (1 question), related to making regulatory approval processes more efficient. Conclusions This is the first reported international research priority setting exercise for AI in colonoscopy. The study findings should be used as a framework to guide future research with key stakeholders to accelerate the clinical implementation of AI in endoscopy.
Publisher: Elsevier BV
Date: 04-2018
Publisher: Wiley
Date: 07-07-2020
DOI: 10.1002/JGH3.12382
Publisher: Baishideng Publishing Group Inc.
Date: 06-01-2019
Publisher: Elsevier BV
Date: 02-2019
DOI: 10.1053/J.GASTRO.2018.10.003
Abstract: Colorectal cancer (CRC) can be prevented by colonoscopy and polypectomy. Endoscopic mucosal resection (EMR) is performed to remove large laterally spreading colonic lesions that have a high risk of progression to CRC. Endoscopically invisible micro-adenomas at the margins of the EMR site might contribute to adenoma recurrence, which occurs in 15% to 30% of patients who undergo surveillance. We aimed to determine the efficacy of adjuvant thermal ablation of the EMR mucosal defect margin in reducing polyp recurrence. We performed a prospective study of 390 patients with large laterally spreading colonic lesions (≥ 20 mm, n = 416) referred for EMR at 4 tertiary centers in Australia. After complete lesion excision by EMR, lesions were randomly assigned to thermal ablation of the post-EMR mucosal defect margin (n = 210) or no additional treatment (controls, n = 206). We performed surveillance colonoscopies with standardized photo documentation and biopsies of the scar after 5 to 6 months. Patient, procedure, and lesion characteristics were similar between the groups. The primary endpoint was detection of lesion recurrence at first surveillance colonoscopy. A significantly lower proportion of patients who received thermal ablation of the post-EMR mucosal defect margin had evidence of recurrence at first surveillance colonoscopy (10/192, 5.2%) than controls (37/176, 21.0%) (P < .001). The relative risk of recurrence in the thermal ablation group was 0.25 compared with the control group (95% confidence interval 0.13-0.48). Rates of adverse events were similar between the groups. In a multicenter randomized trial, thermal ablation of the post-EMR mucosal defect margin significantly reduced polyp recurrence at first surveillance colonoscopy, compared with no additional treatment. Routine implementation of this simple and safe technique could increase the utility of EMR, decrease surveillance burdens, and reduce morbidity and mortality from CRC. ClinicalTrials.gov no: NCT01789749.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2015
DOI: 10.1038/AJG.2015.55
Publisher: Elsevier BV
Date: 04-2017
DOI: 10.1016/J.SOC.2016.10.007
Abstract: Esophagogastric cancer accounts for the second most common cause of cancer-related mortality worldwide. Significant efforts have been made to detect these malignancies at an earlier stage through the implementation of screening programs in high-risk in iduals using advanced diagnostic techniques. Endoscopic management techniques, such as endoscopic mucosal resection and endoscopic submucosal dissection, have consistently demonstrated excellent outcomes in the management of these lesions. These techniques are associated with a lower risk of morbidity and mortality when compared with traditional surgical management.
Publisher: Elsevier BV
Date: 11-2021
Publisher: Wiley
Date: 25-04-2013
DOI: 10.1111/DEN.12075
Abstract: Real-time optical diagnosis of colorectal polyps may lead to substantial time and cost savings and could potentially reduce complications associated with polypectomy. We prospectively assessed the utility of a novel narrow-band imaging (NBI) system with dual focus magnification (DF) in differentiating colorectal polyps in consecutive patients undergoing colonoscopy. All procedures were carried out with a prototype 190 series Exera III NBI system with Dual Focus capability. Histology of each polyp was predicted in real time with NBI-DF based on the modified Sano's classification with a confidence level (low/high). NBI-DF diagnosis was then compared to the final (blinded) histopathology results. Primary endpoint was the accuracy of endoscopic prediction with the modified Sano's classification of all polyps when they were diagnosed with high confidence. Secondary endpoints were the accuracy of post-polypectomy surveillance intervals for diminutive polyps(≤ 5 mm). A total of 164 polyps in 87 patients (53 males) with a mean age of 63 (range 28-86) years were evaluated. 149 polyps were diagnosed with high confidence on endoscopic prediction, out of which 80 were diminutive, 31 small (6-9 mm) and 38 large (>10 mm). Overall accuracy of NBI-DF compared to final histopathology was 97%. The accuracy for post-polypectomy surveillance interval based on the endoscopic prediction was 97%. The NPV for diminutive rectosigmoid polyps for adenomatous histology was 100%. In this preliminary feasibility study, NBI-DF permitted prediction of histology of colorectal polyps with high accuracy. In addition, both of the secondary endpoints exceeded the ASGE PIVI thresholds for the management of diminutive polyps.
Publisher: Wiley
Date: 23-10-2019
DOI: 10.1111/JGH.14868
Abstract: Microbiota have been associated with several diseases including colorectal cancer (CRC). This study aimed to evaluate the microbiota in early/invasive CRC utilizing stool and cytological brushes to determine differences in relative abundance (RA). Colonoscopy patients referred for endoscopic submucosal dissection or previous to CRC surgery were prospectively enrolled. Stool was collected pre-bowel preparation and brush s les were taken during colonoscopy (three regions). DNA extraction, 16S rRNA next generation sequencing, and biostatistics (qiime and st software packages) followed. Primary outcome was the difference in RA of the Fusobacterium genus between the groups. Secondary outcomes included analyses of other microbiota. Twenty-five patients were included, of which 14 had invasive cancer (≥ 1000 mm into the submucosa). The three major genera for invasive cancer were Bacterioides, Oribacterium, and Fusobacterium, whereas for early cancer were Oribacterium, Bacterioides, and Prevotella (decreasing order of RA). There was a significantly higher RA of Fusobacterium in the invasive cancer group (9.65% vs 0.95%, respectively, P < 0.001). The RA of all genera was similar throughout the colon. In addition to Fusobacterium, the genera Corynebacterium, Enterococcus, Neisseria, Porphyromonas, and Sclegelella showed statistically higher RA in the invasive cancer group. Conversely, the genera Oribacterium, Desulfovibrio, Clostridiales, and Lactobacillus showed lower RA in the invasive cancer group. The RA of Fusobacterium is higher with invasive CRC than in early CRC patients. In addition, five other bacteria genera were found to be increased, and four decreased in invasive CRC patients. The microbiota per patient was similar throughout the colon.
Publisher: Wiley
Date: 25-10-2023
DOI: 10.1002/JGH3.12984
Publisher: Wiley
Date: 25-04-2013
DOI: 10.1111/DEN.12114
Abstract: Submucosal invasive colorectal cancers (SM-CRC) have approximately a 10% chance of lymph node metastasis, which requires surgical resection including lymph node dissection for curative treatment. It is important to optimally survey patients after curative resection for SM-CRC in order to detect early recurrence. In the present report, we principally show the long-term outcomes after follow up of SM-CRC resected endoscopically based on a report of the literature and our experience in Japan. The long-term outcomes of low-risk SM-CRC endoscopically resected alone or high-risk SM-CRC with additional surgical resection with lymph node dissection are excellent. However, the risk of local recurrence of endoscopic resection alone in patients with high-risk submucosal invasive cancer was significantly higher in rectal cancer as compared to similar colonic cancer. Patients with submucosal rectal cancer showing high-risk pathological features are, therefore, strongly recommended to undergo additional treatment. We consider that longer follow up is required for patients with SM-CRC because recurrence occurred relatively later in SM-CRC compared to advanced colorectal cancer.
Publisher: Wiley
Date: 2021
DOI: 10.1111/JGH.15354
Publisher: Wiley
Date: 18-04-2012
DOI: 10.1111/J.1440-1746.2010.06333.X
Abstract: Extraordinary developments have occurred in the field of endoscopy over the past 40 years. The era that began with the fiberoptic endoscope (fiberscope) has now moved to the videoscope and, more recently, to the capsule endoscope. Videoendoscopy will remain the major form of endoscopy for the next 5-10 years but, thereafter, diagnostic procedures including colonoscopy will increasingly be performed by capsule endoscopy. This change will be largely driven by patient preference rather than superior results from capsule studies. Image analysis of capsule studies will be accelerated by software that highlights abnormal areas and, by 2025, capsule studies will be 'read' by computer. For the next decade, more complex therapeutic procedures will be performed by a new group of therapeutic endoscopists using advanced videoscopes. Several new therapeutic procedures will emerge but natural orifice transluminal approaches will need to compete with advances in laparoscopic techniques. It is also likely that health administrators faced with escalating medical costs will demand that new and more expensive procedures not only facilitate patient care but result in superior health outcomes.
Publisher: Springer Science and Business Media LLC
Date: 03-09-2018
Publisher: Baishideng Publishing Group Inc.
Date: 21-08-2021
Publisher: Georg Thieme Verlag KG
Date: 26-09-2014
Publisher: Baishideng Publishing Group Inc.
Date: 16-11-2020
Publisher: Wiley
Date: 06-02-2020
DOI: 10.1002/JGH3.12306
Publisher: Wiley
Date: 29-04-2011
DOI: 10.1111/J.1443-1661.2011.01105.X
Abstract: The present recommended strategy for detection of dysplasia and cancer in Barrett's esophagus is by randomly carrying out four quadrant biopsies every 2 cm. This approach is however prone to s ling error. Narrow band imaging has been routinely available for clinical use for more than half a decade now. This review will focus on the available data to date on the role of narrow band imaging in the detection and characterization of specialized intestinal metaplasia, high grade dysplasia and intramucosal cancer in Barrett's esophagus.
Publisher: Elsevier BV
Date: 03-2017
DOI: 10.1016/J.GIE.2016.11.027
Abstract: EMR is the primary treatment of large laterally spreading lesions (LSLs) in the colon. Residual or recurrent adenoma (RRA) is a major limitation. We aimed to identify a robust method to stratify the risk of RRA. Prospective multicenter data on consecutive LSLs ≥20 mm removed by piecemeal EMR from 8 Australian tertiary-care centers were included (September 2008 until May 2016). A logistic regression model for endoscopically determined recurrence (EDR) was created on a randomly selected half of the cohort to yield the Sydney EMR recurrence tool (SERT), a 4-point score to stratify the incidence of RRA based on characteristics of the index EMR. SERT was validated on the remainder of the cohort. Analysis was performed on 1178 lesions that underwent first surveillance colonoscopy (SC1) (median 4.9 months, interquartile range [IQR] 4.9-6.2). EDR was detected in 228 of 1178 (19.4%) patients. LSL size ≥40 mm (odds ratio [OR] 2.47 P < .001), bleeding during the procedure (OR 1.78 P = .024), and high-grade dysplasia (OR 1.72 P = .029) were identified as independent predictors of EDR and allocated scores of 2, 1, and 1, respectively to create SERT. Lesions with SERT scores of 0 (SERT = 0) had a negative predictive value of 91.3% for RRA at SC1, and SERT was shown to stratify RRA to specific follow-up intervals by using Kaplan Meier curves (log-rank P < .001). Guidelines recommend SC1 within 6 months of EMR. SERT accurately stratifies the incidence of RRA after EMR. SERT = 0 lesions could safely undergo first surveillance at 18 months, whereas lesions with SERT scores between 1 and 4 (SERT 1-4) require surveillance at 6 and 18 months. (Clinical trial registration number: NCT01368289.).
Publisher: Georg Thieme Verlag KG
Date: 05-08-2016
Publisher: Wiley
Date: 29-04-2011
DOI: 10.1111/J.1443-1661.2011.01107.X
Abstract: Narrow band imaging with optical magnification (NBI-Z) enables mucosal morphology to be assessed in real time by using light with narrowed band width and magnification of up to 115×. Colorectal lesions detected were assessed with NBI-Z. Histology was predicted using the modified Sano's classification based on capillary network patterns (cn) type I: absent cn (hyperplastic polyp), type II: cn present, surrounding mucosal glands (adenoma), type IIIa: high density cn with tortuosity and lack of uniformity (intramucosal cancer) and type IIIb: nearly avascular cn (invasive cancer). Each lesion was also graded with a confidence level (low/high). High-definition videos (mean 28.2 s range 12-55) of each lesion assessed with NBI-Z were then taken. This was followed by polypectomy, endoscopic or surgical resection. NBI-Z diagnosis was compared with the final histopathology. To test for interobserver agreement, an endoscopist blinded to the video acquisition process/histology was invited to grade the videos. A total of 50 lesions (2 assessors: 100 studies), with an average size of 8.4 mm (range 3-30), in 32 patients were assessed. Twenty were hyperplastic, 25 adenomas, 2 intramucosal and 3 invasive cancers of which 19 were located in the right and 31 in the left colon. The overall accuracy of NBI-Z in predicting histology was 90%, which increased to 95% (88/93) when lesions were predicted with high confidence. The sensitivity (Sn), specificity (Sp), positive (PPV) and negative predictive values (NPV) in differentiating neoplastic from non-neoplastic lesions with high confidence were 98%, 89%, 93% and 97%, respectively, while the Sn, Sp, PPV and NPV in predicting endoscopic resectability (type II, IIIa vs type I, IIIb) was 100%, 90%, 93% and 100%, respectively. The interobserver agreement between both assessors (κ value) was substantial at 0.89. Using confidence levels, NBI-Z permits prediction of colorectal neoplasia with high accuracies and might allow prompt decisions to be made if a lesion should be left in situ, resected and discarded or biopsied. This approach might lead to substantial time and cost savings and could potentially reduce complications associated with polypectomy and endoscopic resections.
Publisher: Elsevier BV
Date: 10-2020
Publisher: Springer Science and Business Media LLC
Date: 16-02-2011
DOI: 10.1007/S10620-011-1609-Y
Abstract: Endoscopic mucosal resection (EMR) is used for treatment of sessile and flat colonic adenomas. There is limited data comparing polyp recurrence between piecemeal and en-bloc resections. The purpose of this study was to evaluate the incidence density and predictive factors for polyp recurrence after piecemeal and en-bloc resections. Patients undergoing EMR of flat or sessile adenomas≥10 mm were included. Incidence density (ID) and incidence rate ratio (IRR) of polyp recurrence were calculated. Predictive factors for recurrence were assessed by multivariate analysis using logistic regression. A total of 105 patients (males 54, mean age 68) with 121 polyps were included. Sixty-seven polyps (mean size±SD, 23.3±9.2 mm) were resected piecemeal and 54 polyps (mean size 14.7±5.1 mm) were resected en-bloc. There were 12 recurrences in the piecemeal group and two in the en-bloc group. The ID of polyp recurrence in the piecemeal group was 13.1 (95% CI 7.43-23.03) and in the en-bloc group was 2.7 (95% CI 0.67-10.78) per 100 person-years of follow-up. Piecemeal resections were 5.5 (95% CI 1.1-30.48, P=0.045) times and flat polyps were 6.6 (95% CI 1.22-35.53, P=0.028) times more likely to result in recurrence compared to en-bloc resections and sessile polyps, respectively. In the piecemeal group, additional use of argon plasma coagulation (APC) did not affect the recurrence (OR 0.46, P=0.29). Piecemeal resections and flat polyps are associated with higher recurrence following EMR. Additional use of APC did not affect the recurrence rates after piecemeal resection.
Publisher: Georg Thieme Verlag KG
Date: 21-03-2019
DOI: 10.1055/A-0854-3525
Abstract: Background and study aims Image enhanced endoscopy (IEE) allows endoscopists to improve recognition and characterization of gastrointestinal neoplasia. The Asian Novel Bio-Imaging and Intervention Group (ANBIG) conducted a standardized training program in endoscopic diagnosis and treatment of early gastrointestinal cancers in Asia. We embarked on a study to investigate the effect of this module on endoscopic diagnosis of early gastrointestinal neoplasia. Methods This prospectively collected database was from workshops conducted on training for endoscopic diagnosis of early gastrointestinal neoplasia. All workshops were conducted in a standardized format, which included a pretest, a learning phase consisting of didactic lectures, case discussion, and live demonstration followed by a post-test to assess knowledge gained. The pretest and post-training tests were standardized questions addressing four domains, including basic knowledge of imaging and diagnosis of esophageal, gastric, and colonic neoplasia. Results From November 2013 to November 2016, 41 ANBIG workshops were conducted in 13 countries. A total of 1863 delegates and 40 faculty participated in these workshops. Of the delegates, 627 completed both tests. There was a significant improvement after training in all domains of the tests. There was a trend in general lack of knowledge across all domains for delegates from “low” healthcare cost countries before training. All delegates demonstrated significant improvement in knowledge of all domains after the workshop irrespective of whether they were from “high” or “low” healthcare cost per capita countries. Conclusion A standardized teaching program on IEE improved the diagnostic ability and quality of endoscopists in recognizing early gastrointestinal neoplasia in Asia.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2015
DOI: 10.1038/AJG.2015.151
Publisher: The Editorial Office of Gut and Liver
Date: 15-07-2021
DOI: 10.5009/GNL20031
Publisher: Baishideng Publishing Group Inc.
Date: 2016
Abstract: It is currently known that colorectal cancers (CRC) arise from 3 different pathways: the adenoma to carcinoma chromosomal instability pathway (50%-70%) the mutator "Lynch syndrome" route (3%-5%) and the serrated pathway (30%-35%). The World Health Organization has classified serrated polyps into three types of lesions: hyperplastic polyps (HP), sessile serrated adenomas olyps (SSA/P) and traditional serrated adenomas (TSA), the latter two strongly associated with development of CRCs. HPs do not cause cancer and TSAs are rare. SSA/P appear to be the responsible precursor lesion for the development of cancers through the serrated pathway. Both HPs and SSA/Ps appear morphologically similar. SSA/P are difficult to detect. The margins are normally inconspicuous. En bloc resection of these polyps can hence be troublesome. A careful examination of borders, submucosal injection of a dye solution (for larger lesions) and resection of a rim of normal tissue around the lesion may ensure total eradication of these lesions.
Publisher: Elsevier BV
Date: 09-2017
DOI: 10.1053/J.GASTRO.2017.05.047
Abstract: Among patients with large colorectal sessile polyps or laterally spreading lesions, it is important to identify those at risk for submucosal invasive cancer (SMIC). Lesions with overt endoscopic evidence of SMIC are referred for surgery, although those without these features might still contain SMIC that is not visible on endoscopic inspection (covert SMIC). Lesions with a high covert SMIC risk might be better suited for endoscopic submucosal dissection than for endoscopic mucosal resection (EMR). We analyzed a group of patients with large colon lesions to identify factors associated with SMIC, and examined lesions without overt endoscopic high-risk signs to determine factors associated with covert SMIC. We performed a prospective cohort study of consecutive patients referred for EMR of large sessile or flat colorectal polyps or laterally spreading lesions (≥20 mm) at academic hospitals in Australia from September 2008 through September 2016. We collected data on patient and lesion characteristics, outcomes of procedures, and histology findings. We excluded serrated lesions from the analysis of covert SMIC due to their distinct phenotype and biologic features. We analyzed 2277 lesions (mean size, 36.9 mm) from 2106 patients (mean age, 67.7 years 53.2% male). SMIC was evident in 171 lesions (7.6%). Factors associated with SMIC included Kudo pit pattern V, a depressed component (0-IIc), rectosigmoid location, 0-Is or 0-IIa+Is Paris classification, non-granular surface morphology, and increasing size. After exclusion of lesions that were obviously SMIC or serrated, factors associated with covert SMIC were rectosigmoid location (odds ratio, 1.87 P = .01), combined Paris classification, surface morphology (odds ratios, 3.96-22.5), and increasing size (odds ratio, 1.16/10 mm P = .012). In a prospective study of 2106 patients who underwent EMR for large sessile or flat colorectal polyps or laterally spreading lesions, we associated rectosigmoid location, combined Paris classification and surface morphology, and increasing size with increased risk for covert malignancy. Rectosigmoid 0-Is and 0-IIa+Is non-granular lesions have a high risk for malignancy, whereas proximally located 0-Is or 0-IIa granular lesions have a low risk. These findings can be used to inform decisions on which patients should undergo endoscopic submucosal dissection, EMR, or surgery. ClinicalTrials.gov, Number: NCT02000141.
Publisher: Informa UK Limited
Date: 11-2011
DOI: 10.1586/EGH.11.80
Abstract: Esophageal cancers have traditionally been diagnosed late and prognosis has been dire. For many years the only real treatment option was esophagectomy with substantial morbidity and mortality. This situation has now changed dramatically. Improvements have been achieved in surgical outcomes and there is an array of new effective treatment options now available, particularly for the increasing proportion diagnosed with early-stage disease. Minimally invasive endoscopic therapies can now prevent, cure or palliate esophageal cancers. This article aims to investigate the role and evidence base for these new therapeutic options.
Publisher: John Wiley & Sons, Ltd
Date: 12-05-2010
Publisher: BMJ
Date: 07-03-2022
DOI: 10.1136/GUTJNL-2020-323666
Abstract: Management of covert submucosal invasive cancer (SMIC) discovered after piecemeal endoscopic mucosal resection (pEMR) of large ( mm) non-pedunculated colorectal polyps is challenging. The residual cancer risk is largely unknown. We sought to evaluate this in a large tertiary referral cohort. Cases of covert SMIC following pEMR were identified and followed. Oncological outcomes after surgery were ided based on residual intramural cancer, lymph node metastases (LNM) or both. Risk factors for residual intramural cancer and LNM were analysed based on the original pEMR histological variables. Risk parameters were analysed with respect to low and high-risk variables for residual intramural cancer and LNM. Among 3372 cases of large non-pedunculated colorectal polyps, 143 cases of covert SMIC (4.2%) were identified. 109 underwent surgical resection. Histological analysis of pEMR histology was available in 98 of 109 (90%) cases. 62 cases (63%) had no residual malignancy. 36 cases had residual malignancy (residual intramural cancer n=24 LNM n=5 both n=7). All cases of residual intramural cancer could be identified by a R1 histological deep margin. Cases with poor differentiation (PD) and/or lymphovascular invasion (LVI) had a high risk of LNM (12/33), with a very low risk without these criteria ( % 0/65). Cases at low risk for LNM with R0 deep margin have a low risk of residual intramural cancer ( % 0/35). The majority of cases of large non-pedunculated colorectal polyps with covert SMIC following pEMR will have no residual malignancy. The risk of residual malignancy can be ascertained from three key variables: PD, LVI and R1 deep margin.
Publisher: Georg Thieme Verlag KG
Date: 31-05-2017
Abstract: Background and study aims Endoscopic mucosal resection (EMR) of laterally spreading colonic lesions ≥ 20 mm (LSLs) is ideally performed in a single session (ssEMR) and avoids surgery in 90 % of patients. We investigated whether a second attempt is safe or useful when ssEMR fails at a tertiary center. Patients and methods In a multicenter prospective observational study of patients with LSL treated by EMR at four tertiary centers over 8 years, incompletely resected LSLs were referred for surgery or underwent two-stage EMR (tsEMR). At tsEMR, the scar was located and all visible residual tissue removed by snare, with thermal treatment permitted thereafter. Scheduled surveillance was performed at 5 months (SC1) and 18 months (SC2). The primary outcome was avoidance of surgery. Results A total of 1944 LSLs (median size 35 mm) underwent EMR. ssEMR was unsuccessful in 127 lesions, 43 of which underwent tsEMR, with success in 36 (83.7 %). Compared with ssEMR, tsEMR lesions were larger (median size 50 mm vs. 30 mm P 0.001), exhibited more submucosal fibrosis (P 0.001), and histology was more often tubular adenoma and less often serrated (P = 0.005). Lesions mainly required tsEMR for nonlifting (41.9 %) or poor endoscopic access (37.2 %). Failure of tsEMR was predicted by larger LSL (P = 0.03). Safety was comparable to ssEMR. Of the 33 LSLs that underwent tsEMR for benign disease and completed first surveillance, 27 (81.8 %) avoided surgery to long term follow-up. Conclusions tsEMR shows promise as a salvage therapy for LSLs that cannot be resected in a single session for patients in whom other options such as surgery are not preferred or not possible. Trial registered at ClinicalTrials.gov (NCT01368289).
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2016
Publisher: Baishideng Publishing Group Inc.
Date: 2017
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2016
DOI: 10.1038/AJG.2016.235
Abstract: Clinically significant bleeding (CSPEB) is the most frequent adverse event following wide-field endoscopic mucosal resection (WF-EMR) of large sessile and laterally spreading colorectal lesions (LSL). There is limited knowledge regarding accurate prediction of CSPEB. We aimed to derive a score to predict the risk of CSPEB. Data on patient and lesion characteristics and outcomes from WF-EMRs of LSL ≥20 mm at 8 referral hospitals were analyzed. The cohort was ided at random into equal sized training and test groups. Independent predictors of CSPEB in the training cohort were identified by multiple logistic regression analysis and used to develop a risk score. The performance of this score was assessed in the independent test cohort. Over 80 months to June 2015, 2,128 patients with 2,424 LSL were referred for WF-EMR. Two thousand and twelve patients were eligible for analysis. There were 135 cases of CSPEB (6.7%). In the training cohort of 1,006 patients, the independent predictors of CSPEB were lesion size >30 mm (odds ratio (OR) 2.5), proximal colonic location (OR 2.3), presence of a major comorbidity (OR 1.5), and epinephrine in injection solution (OR 0.57). The derived risk score comprised lesion size >30 mm (2 points), proximal colon (2 points), presence of major comorbidity (1 point), and absence of epinephrine use (1 point). The probabilities of CSPEB for scores of 0, 1, 2, 3, 4, and ≥5 in the training cohort were 1.5, 2.0, 5.6, 7.8, 9.1, and 17.5% and were 0.9, 6.7, 4.9, 6.2, 9.0, and 15.7% in the test cohort. The probabilities of CSPEB in those with low (score 0-1), medium (score 2-4), and elevated (score 5-6) risk levels were 1.7, 7.1, and 17.5% in the training cohort and 3.4, 6.2, and 15.7% in the test cohort. Patients at elevated risk of CSPEB can be identified using four readily available variables. This knowledge may improve the management of those undergoing WF-EMR and assist in designing studies evaluating CSPEB.
Publisher: BMJ
Date: 19-01-2016
DOI: 10.1136/GUTJNL-2015-310249
Abstract: Endoscopic mucosal resection (EMR) is effective for large laterally spreading flat and sessile lesions (LSLs). Sessile serrated adenomas olyps (SSA/Ps) are linked to the relative failure of colonoscopy to prevent proximal colorectal cancer. We aimed to examine the technical success, adverse events and recurrence following EMR for large SSA/Ps in comparison with large conventional adenomas. Over 74 months till August 2014, prospective multicentre data of LSLs ≥20 mm were analysed. A standardised dye-based conventional EMR technique followed by scheduled surveillance colonoscopy was used. From a total of 2000 lesions, 323 SSA/Ps in 246 patients and 1527 adenomas in 1425 patients were included for analysis. Technical success for EMR was superior in SSA/Ps compared with adenomas (99.1% vs 94.5%, p<0.001). Significant bleeding and perforation were similar in both cohorts. The cumulative recurrence rates for adenomas after 6, 12, 18 and 24 months were 16.1%, 20.4%, 23.4% and 28.4%, respectively. For SSA/Ps, they were 6.3% at 6 months and 7.0% from 12 months onwards (p<0.001). Following multivariable adjustment, the HR of recurrence for adenomas versus SSA/Ps was 1.7 (95% CI 0.9 to 3.0, p=0.097). Subgroup analysis by lesion size revealed an eightfold increased risk of recurrence for 20-25 mm adenomas versus SSA/Ps, but no significantly different risk between lesion types in larger lesion groups. Recurrence after EMR of 20-25 mm LSLs is significantly less frequent in SSA/Ps compared with adenomatous lesions. SSA/Ps can be more effectively removed than adenomatous LSLs with equivalent safety. Ensuring complete initial resection is imperative for avoiding recurrence. ClinicalTrials.gov NCT01368289.
Publisher: Wiley
Date: 26-02-2013
DOI: 10.1111/JGH.12098
Abstract: Diminutive polyps measuring ≤ 5 mm in size constitute 80% of polyps in the colon. We prospectively assessed the performance of high-definition white light endoscopy (hWLE) and narrow band imaging (NBI) in differentiating diminutive colorectal polyps. In this prospective, multicenter study, videos of 50 diminutive polyps (31 hyperplastic, 19 adenomatous) in hWLE followed by NBI (total 100 videos) were initially obtained and placed in random order into five separate folders (each folder 20 videos). Eight endoscopists were then invited to predict the histology (each endoscopist 100 videos, 800 video assessments in all). Polyps were classified into types 1-3 (hyperplastic) and type 4 (adenoma). Feedback on in idual performance was given after each folder (20 videos) was assessed. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy in differentiating hyperplastic from adenomatous polyps by hWLE (400 videos) and NBI (400 videos) were 67.8%, 90.7%, 81.7%, 82.1%, and 82.0% and 82.2%, 81.5%, 73.1%, 88.2%, and 81.8%, respectively. In the pretest and post-test analysis, the accuracy with NBI improved markedly from 68.8% to 91.3% (P = 0.001) compared with hWLE, 76.3-78.8% (P = 0.850). Overall, the interobserver agreement was 0.46 for hWLE (moderate) and 0.64 for NBI (good). NBI was as accurate as hWLE in differentiating diminutive colorectal polyps. Once a learning curve was reached, NBI achieved significantly higher accuracies with good interobserver agreement. Using a simplified classification, a didactic learning session and feedback on performance, diminutive colorectal polyps could be predicted with high accuracies with NBI.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2018
Publisher: Wiley
Date: 29-04-2011
DOI: 10.1111/J.1443-1661.2011.01139.X
Abstract: Reported herein is the case of a 80-year-old man who had small squamous cell carcinoma in the esophagus. The lesion was initially detected as a irregular reddish elevated and flat area depicted by non-magnified white light endoscopy and observed as a brownish area with the narrow-band imaging system (NBI). The depth of elevated and depressed area in the lesion was predicted to be LSM to MM due to Inoue's classification of morphologic change of intrapapillary capillary loop (IPCL) under magnified NBI observation. The depth of another flat area was not able to predicted by Inoue's classification, and we used Arima's classification. We predicted the depth of invasion to be MM to SM1.by this classification. Endoscopic submucosal dissection (ESD) was carried out for the lesion. As a result, the endoscopic diagnosis completely accorded with pathological diagnosis. We could diagnose correctly by adding Arima's classification to Inoue's classification.
Publisher: Wiley
Date: 21-11-2018
DOI: 10.1111/JGH.14511
Abstract: Outbreaks of carbapenemase-producing Enterobacteriaceae clinical infections related to endoscopic transmission are well documented. The high morbidity and mortality associated with these infections emphasizes the need to reassess endoscopic reprocessing protocols. The Gastroenterological Society of Australia established a multi-society committee to formulate evidence-based consensus statements on the prevention and management of endoscopic transmission of carbapenemase-producing Enterobacteriaceae. A literature search was undertaken utilizing the MEDLINE database. Further references were sourced from published paper bibliographies. Nine statements were formulated. Using the Delphi methodology, the statements were initially reviewed electronically by the committee members and subsequently at a face-to-face meeting in Melbourne, Australia. After further discussion, four additional sub-statements were added resulting in a total of 13 statements. Each statement was assessed for level of evidence, recommendation grade and the voting on recommendation was recorded. For a statement to be accepted, five out of six committee members had to "accept completely" or "accept with some reservation." All 13 statements achieved consensus agreement. Eleven statements achieved 100% "accepted completely." Two statements were 83% "accepted completely" and 17% "accepted with some reservation." Of particular significance, automated flexible endoscope reprocessors were mandated for high-level disinfection, and the use of forced-air drying cabinets was mandated for endoscope storage. These evidence-based statements encourage preventative strategies with the aim of ensuring the highest possible standards in flexible endoscope reprocessing thereby optimizing patient safety. They must be considered in addition to the broader published guidelines on infection control in endoscopy.
Publisher: Baishideng Publishing Group Inc.
Date: 2011
Publisher: Elsevier BV
Date: 06-2011
DOI: 10.1053/J.GASTRO.2011.02.062
Abstract: Large sessile colonic polyps usually are managed surgically, with significant morbidity and potential mortality. There have been few prospective, intention-to-treat, multicenter studies of endoscopic mucosal resection (EMR). We investigated whether endoscopic criteria can predict invasive disease and direct the optimal treatment strategy. The Australian Colonic Endoscopic (ACE) resection study group conducted a prospective, multicenter, observational study of all patients referred for EMR of sessile colorectal polyps that were 20 mm or greater in size (n=479, mean age, 68.5 y mean lesion size, 35.6 mm). We analyzed data on lesion characteristics and procedural, clinical, and histologic outcomes. Multiple logistic regression analysis identified independent predictors of EMR efficacy and recurrence of adenoma, based on findings from follow-up colonoscopy examinations. Risk factors for submucosal invasion were as follows: Paris classification 0-IIa+c morphology, nongranular surface, and Kudo pit pattern type V. The most commonly observed lesion (0-IIa granular) had a low rate of submucosal invasion (1.4%). EMR was effective at completely removing the polyp in a single session in 89.2% of patients risk factors for lack of efficacy included a prior attempt at EMR (odds ratio [OR], 3.8 95% confidence interval, 1.77-7.94 P=.001) and ileocecal valve involvement (OR, 3.4 95% confidence interval, 1.20-9.52 P=.021). Independent predictors of recurrence after effective EMR were lesion size greater than 40 mm (OR, 4.37 95% confidence interval, 2.43-7.88 P<.001) and use of argon plasma coagulation (OR, 3.51 95% confidence interval, 1.69-7.27 P=.0017). There were no deaths from EMR 83.7% of patients avoided surgery. Large sessile colonic polyps can be managed safely and effectively by endoscopy. Endoscopic assessment identifies lesions at increased risk of containing submucosal cancer. The first EMR is an important determinant of patient outcome-a previous attempt is a significant risk factor for lack of efficacy.
Publisher: Wiley
Date: 25-04-2013
DOI: 10.1111/DEN.12106
Abstract: This preliminary feasibility study assessed the utility of a novel narrow-band imaging (NBI) system (Olympus Exera III 190 series) both as a detection and as a characterization tool in patients undergoing surveillance endoscopy for Barrett's esophagus (BE). Two hundred and twenty-one areas in 40 patients with BE were examined prospectively. The BE segment was initially evaluated with NBI overview as a 'red flag' technique. Abnormal areas identified with NBI overview were then further interrogated with NBI and a dual focus (DF) magnification system (NBI-DF) in order to aid characterization. Normal areas on NBI overview were also systematically assessed with NBI-DF systematically (four quadrants every 2 cm). A confidence system was utilized when each area was assessed with NBI-DF. All areas on NBI-DF were classified into three easily distinguishable mucosal patterns: (i) regular pits with regular microvasculature (no dysplasia) (ii) irregular pits with irregular microvasculature (early cancer/high-grade dysplasia [HGD]) and (iii) equivocal, where the endoscopist was not sure about the pattern (this could be areas with increased brownish discoloration on NBI overview and dilated vasculature but no change in caliber on NBI-DF [likely inflammation or low-grade dysplasia: LGD]). Corresponding biopsies of each area were then taken. The sensitivity (Sn), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of both modes (NBI overview and NBI-DF) were then compared with the final histopathological diagnosis. One hundred and eighty-three of 221 areas (82.8%) did not exhibit any dysplasia on final histopathological assessment. NBI overview and NBI-DF accurately called all these areas as non-dysplastic. The 38 areas that appeared suspicious on NBI overview were also further assessed with NBI-DF: seven of seven were accurately predicted as harboring no dysplasia nine areas were predicted as irregular, of which four harbored early cancer, one HGD, three LGD and one inflammation on final histopathology assessment. Twenty-two areas were deemed to be equivocal (final histology: 18 LGD and four inflammation). The Sn, Sp, PPV and NPV for the prediction of dysplasia/early cancer using NBI overview and NBI-DF were thus 100%, 93.8%, 68.6%, 100% and 100%, 86.2%, 73.3%, 100%, respectively. If NBI-DF was used in addition to NBI overview, biopsies would have been avoided in 190 areas (86%). In addition, all early cancers and HGD could be accurately identified.
Publisher: S. Karger AG
Date: 2020
DOI: 10.1159/000505622
Abstract: b i Introduction: /i /b Quality measures for colonoscopy such as adenoma detection rate (ADR) have been proposed to be surveilled for ensuring minimum standards. However, its direct measurement is time consuming and often neglected. Extrapolating ADR and other quality measures from polyp detection rate (PDR) can be a pragmatic alternative. b i Objective: /i /b To determine quotients for estimating ADR and sessile serrated adenoma olyp detection rate (SSA/P-DR) from PDR in an Australian cohort. b i Methods: /i /b Consecutive adult patient colonoscopies during a 1-year period were retrospectively assessed in a single Australian tertiary endoscopy center. Adenoma detection quotient (ADQ) and SSA/P detection quotient (SSA/P-DQ) were defined as the ision of ADR and SSA/P-DR by PDR, respectively. The primary outcome was the number of procedures to achieve a stable cumulative ADQ and SSA/P-DQ. Secondary outcomes included evaluation of ADQ and SSA/P-DQ in different subsets. b i Results: /i /b In total, 2,657 colonoscopies were performed by 15 endoscopists in 2016. The ADR, SSA/P-DR, and PDR found were 32.2, 6.7, and 47.3%, respectively. The ADQ and SSA/P-DQ values found were 0.68 and 0.14, respectively. After approximately 500 procedures, both ADQ and SSA/P-DQ became stable. Interclass correlation coefficient (ICC) for the prediction of ADR from ADQ was excellent for all endoscopists that performed & #x3e procedures in that year (ICC 0.84). b i Conclusions: /i /b ADQ and SSA/P-DQ values were consistent when over 500 procedures were analyzed. ADQ had an excellent correlation with ADR when & #x3e procedures per endoscopist were evaluated.
Publisher: Elsevier BV
Date: 03-2020
DOI: 10.1016/J.CGH.2021.01.007
Abstract: Although perforation is the most feared adverse event associated with endoscopic mucosal resection (EMR), limited data exists concerning its management. Therefore, we sought to evaluate the short- and long-term outcomes of intra-procedural deep mural injury (DMI) in an international multi-center observational cohort of large (≥20 mm) non-pedunculated colorectal polyps (LNPCPs). Consecutive patients who underwent EMR for a LNPCP ≥20 mm were evaluated. Significant DMI (S-DMI) was defined as Sydney DMI Classification type III (muscularis propria injury, target sign) or type IV/V (perforation without or with contamination, respectively). The primary outcome was successful S-DMI defect closure. Secondary outcomes included technical success (removal of all visible polypoid tissue during index EMR), surgical referral and recurrence at first surveillance colonscopy (SC1). Between July 2008 to May 2020, 3717 LNPCPs underwent EMR. Median lesion size was 35mm (interquartile range (IQR) 25 to 45mm). Significant DMI was identified in 101 cases (2.7%), with successful defect closure in 98 (97.0%) using a median of 4 through-the-scope clips (TTSCs IQR 3 to 6 TTSCs). Three (3.0%) patients underwent S-DMI-related urgent surgery. Technical success was achieved in 94 (93.1%) patients, with 46 (45.5%) admitted to hospital (median duration 1 day IQR 1 to 2 days). Comparing LNPCPs with and without S-DMI, no differences in technical success (94 (93.1%) vs 3316 (91.7%) P = .62) or SC1 recurrence (12 (20.0%) vs 363 (13.6%) P = .15) were identified. Significant DMI is readily managed endoscopically and does not appear to affect technical success or recurrence.
Publisher: Elsevier BV
Date: 02-2016
DOI: 10.1016/J.CGH.2015.08.037
Abstract: Large laterally spreading lesions (LSL) in the colon and rectum can be safely and effectively removed by endoscopic mucosal resection (EMR). However, many patients still undergo surgery. Endoscopic treatment may be more cost effective. We compared the costs of endoscopic versus surgical management of large LSL. We performed a prospective, observational, multicenter study of consecutive patients referred to 1 of 7 academic hospitals in Australia for the management of large LSL (≥ 20 mm) from January 2010 to December 2013. We collected data on numbers of patients undergoing EMR, actual endoscopic management costs (index colonoscopy, hospital stay, adverse events, and first surveillance colonoscopy), characteristics of patients and lesions, outcomes, and adverse events, and findings from follow-up examinations 14 days, 4-6 months, and 16-18 months after treatment. We compared data from patients who underwent EMR with those from a model in which all patients underwent surgery without any complications. Event-specific costs, based on Australian refined diagnosis-related group codes, were used to estimate average cost per patient. EMR was performed on 1489 lesions (mean size, 36 mm) in 1353 patients (mean age, 67 years 52.1% male). Total costs involved in the endoscopic management of large LSL were US $6,316,593 and total inpatient hospitalization length of stay was 1180 days. The total cost predicted for the surgical management group was US $16,601,502, with a total inpatient hospitalization length of stay of 4986 days. Endoscopic management produced a potential total cost saving of US $10,284,909 the mean cost difference per patient was US $7602 (95% confidence interval, $8458-$9220 P < .001). Inpatient hospitalization length of stay was reduced by 2.81 nights per patient (95% confidence interval, 2.69-2.94 P < .001). In a large multicenter study, endoscopic management of large LSL by EMR was significantly more cost-effective than surgery. Endoscopic management by EMR at an appropriately experienced and resourced tertiary center should be considered the first line of therapy for most patients with this disorder. This approach is likely to deliver substantial overall health expenditure savings. ClinicalTrials.gov, Number: NCT01368289.
Publisher: Hindawi Limited
Date: 2016
DOI: 10.1155/2016/3296801
Abstract: What should be done next? Is the stricture benign? Is it resectable? Should I place a stent? Which one? These are some of the questions one ponders when dealing with biliary strictures. In resectable cases, ongoing questions remain as to whether the biliary tree should be drained prior to surgery. In palliative cases, the relief of obstruction remains the main goal. Options for palliative therapy include surgical bypass, percutaneous drainage, and stenting or endoscopic stenting (transpapillary or via an endoscopic ultrasound approach). This review gathers scientific foundations behind these interventions. For operable cases, preoperative biliary drainage should not be performed unless there is evidence of cholangitis, there is delay in surgical intervention, or intense jaundice is present. For inoperable cases, transpapillary stenting after sphincterotomy is preferable over percutaneous drainage. The use of plastic stents (PS) has no benefit over Self-Expandable Metallic Stents (SEMS). In case transpapillary drainage is not possible, Endoscopic Ultrasonography- (EUS-) guided drainage is still an option over percutaneous means. There is no significant difference between the types of SEMS and its indication should be in idualized.
Publisher: Elsevier BV
Date: 12-2023
Location: Australia
No related grants have been discovered for Rajvinder Singh.