Lobke Desomer

A standardized imaging protocol is accurate in detecting recurrence after EMR

BACKGROUND AND AIMSnEMR of large laterally spreading lesions (LSL) in the colon is a safe and effective alternative to surgery. Post-EMR scar assessment currently involves taking biopsy specimens of the scar to detect residual or recurrent adenoma (RRA). The accuracy of endoscopic imaging of the post-EMR scar is unknown. We aimed to determine the accuracy of a standardized imaging protocol in post-EMR scar assessment.nnnMETHODSnProspective, single-center data from the Australian Colonic EMR study were analyzed. Consecutive patients undergoing first surveillance colonoscopy (SC1) after EMR of a large LSL were eligible. All scars were sequentially examined with high-definition white light (HD-WL) and narrow-band imaging (NBI) in a standardized fashion and then biopsies were performed. Endoscopic recurrence (recurrence at the post-EMR scar detected by systematic endoscopic assessment) was compared with the histologic findings.nnnRESULTSnOne hundred eighty-three post-EMR scars were included. Thirty of 183 (16.4%) were confirmed to have RRA histologically at SC1. Thirty-seven of 183 (20.2%) post-EMR scars demonstrated RRA endoscopically. The sensitivity and specificity of endoscopic RRA detection were 93.3% (95% confidence interval [CI], 77.9%-99.2%) and 94.1% (95% CI, 89.1%-97.3%), respectively. The positive predictive value was 75.7% (95% CI, 58.8%-88.2%) and the negative predictive value was 98.6% (95% CI, 95.1%-99.8%). The diagnostic accuracy was 94.0%. Sensitivity was higher for the combination of HD-WL and NBI as opposed to HD-WL alone (93.3% vs 66.7%). The specificity was high for both HD-WL and HD-WLxa0+ NBI (96.1% and 94.1%, respectively). Flat morphology of RRA was better seen with NBI (Pxa0= .002).nnnCONCLUSIONSnEndoscopic detection of RRA in the post-EMR scar is highly accurate using a standardized imaging protocol with HD-WL and NBI. This allows real-time, accurate detection of recurrence and its concurrent treatment, and raises the possibility that routine biopsy of the post-EMR scar may not be necessary.

Adenoma recurrence after piecemeal colonic EMR is predictable: the Sydney EMR recurrence tool

BACKGROUND AND AIMSnEMR 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.nnnMETHODSnProspective multicenter data on consecutive LSLsxa0≥20xa0mm 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.nnnRESULTSnAnalysis 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 sizexa0≥40xa0mm (odds ratio [OR] 2.47; Pxa0< .001), bleeding during the procedure (OR 1.78; Pxa0= .024), and high-grade dysplasia (OR 1.72; Pxa0= .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 (SERTxa0= 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 Pxa0< .001).nnnCONCLUSIONSnGuidelines recommend SC1 within 6 months of EMR. SERT accurately stratifies the incidence of RRA after EMR. SERTxa0= 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.).

Wide-field piecemeal cold snare polypectomy of large sessile serrated polyps without a submucosal injection is safe

BACKGROUND AND STUDY AIMSu2002: Large series suggest endoscopic mucosal resection is safe and effective for the removal of large (≥u200a10u200amm) sessile serrated polyps (SSPs), but it exposes the patient to the risks of electrocautery, including delayed bleeding. We examined the feasibility and safety of piecemeal cold snare polypectomy (pCSP) for the resection of large SSPs.nnnMETHODSnSequential large SSPs (10u200a-u200a35u200amm) without endoscopic evidence of dysplasia referred over 12 months to a tertiary endoscopy center were considered for pCSP. A thin-wire snare was used in all cases. Submucosal injection was not performed. High definition imaging of the defect margin was used to ensure the absence of residual serrated tissue. Adverse events were assessed at 2 weeks and surveillance was planned for between 6 and 12 months.nnnRESULTSn41 SSPs were completely removed by pCSP in 34 patients. The median SSP size was 15u200amm (interquartile range [IQR] 14.5u200a-u200a20 mm; range 10u200a-u200a35u200amm). The median procedure duration was 4.5 minutes (IQR 1.4u200a-u200a6.3 minutes). There was no evidence of perforation or significant intraprocedural bleeding. At 2-week follow-up, there were no significant adverse events, including delayed bleeding and post polypectomy syndrome. First follow-up has been undertaken for 15u200a/41 lesions at a median of 6 months with no evidence of recurrence.nnnCONCLUSIONSnThere is potential for pCSP to become the standard of care for non-dysplastic large SSPs. This could reduce the burden of removing SSPs on patients and healthcare systems, particularly by avoidance of delayed bleeding.

Cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST) is an effective and safe strategy for the management of non-lifting large laterally spreading colonic lesions

BACKGROUND AND AIMSnNon-lifting large laterally spreading colorectal lesions (LSLs) are challenging to resect endoscopically and often necessitate surgery. A safe, simple technique to treat non-lifting LSLs endoscopically with robust long-term outcomes has not been described.nnnMETHODSnIn this single-center prospective observational study of consecutive patients referred for endoscopic mucosal resection (EMR) of LSLs ≥u200a20u200amm, LSLs not completely resectable by snare because of non-lifting underwent standardized completion of resection with cold-forceps avulsion and adjuvant snare-tip soft coagulation (CAST). Scheduled surveillance colonoscopies were performed at 4u200a-u200a6 months (SC1) and 18 months (SC2). Primary outcomes were endoscopic evidence of adenoma clearance and avoidance of surgery. The secondary outcome was safety.nnnRESULTSnFrom January 2012 to October 2016, 540 lifting LSLs (82.2u200a%) underwent complete snare excision at EMR. CAST was required for complete removal in 101 non-lifting LSLs (17.8u200a%): 63 naïve non-lifting lesions (NNLs; 62.7u200a%) and 38 previously attempted non-lifting lesions (PANLs; 37.3u200a%). PANLs were smaller (Pu200a<u200a0.001) and more likely to be non-granular (Pu200a=u200a0.001) than the lifting LSLs. NNLs were of similar size (Pu200a=u200a0.77) and morphology (Pu200a=u200a0.10) to the lifting LSLs. CAST was successful in all cases and adverse events were comparable to lifting LSLs resected by complete snare excision. Recurrence at SC1 was comparable for PANLs (15.2u200a%) and lifting LSLs (15.3u200a%; Pu200a=u200a0.99), whereas NNLs recurred more frequently (27.5u200a%; Pu200a=u200a0.049); however, surgery was no more common for either type of non-lifting LSL than for lifting LSLs.nnnCONCLUSIONnCAST is a safe, effective, and surgery-sparing therapy for the majority of non-lifting LSLs. It is easy to use, inexpensive, and does not require additional equipment.

A standardized imaging protocol for the endoscopic prediction of dysplasia within sessile serrated polyps (with video)

BACKGROUND AND AIMSnDysplasia within sessile serrated polyps (SSPs) is difficult to detect and may be mistaken for an adenoma, risking incomplete resection of the background serrated tissue, and is strongly implicated in interval cancer after colonoscopy. The use of endoscopic imaging to detect dysplasia within SSPs has not been systematically studied.nnnMETHODSnConsecutively detected SSPsxa0≥8xa0mm in size were evaluated by using a standardized imaging protocol at a tertiary-care endoscopy center over 3 years. Lesions suspected as SSPs were analyzed with high-definition white light then narrow-band imaging. A demarcated area with a neoplastic pit pattern (Kudo type III/IV, NICE type II) was sought among the serrated tissue. If this was detected, the lesion was labeled dysplastic (sessile serrated polyp with dysplasia); if not, it was labeled non-dysplastic (sessile serrated polyp without dysplasia). Histopathology was reviewed by 2 blinded specialist GI pathologists.nnnRESULTSnA total of 141 SSPs were assessed in 83 patients. Median lesion size was 15.0xa0mm (interquartile range 10-20), and 54.6% were in the right side of the colon. Endoscopic evidence of dysplasia was detected in 36 of 141 (25.5%) SSPs; of these, 5 of 36 (13.9%) lacked dysplasia at histopathology. Two of 105 (1.9%) endoscopically designated non-dysplastic SSPs had dysplasia at histopathology. Endoscopic imaging, therefore, had an accuracy of 95.0% (95% confidence interval [CI], 90.1%-97.6%) and a negative predictive value of 98.1% (95% CI, 92.6%-99.7%) for detection of dysplasia within SSPs.nnnCONCLUSIONSnDysplasia within SSPs can be detected accurately by using a simple, broadly applicable endoscopic imaging protocol that allows complete resection. Independent validation of this protocol and its dissemination to the wider endoscopic community may have a significant impact on rates of interval cancer. (Clinical trial registration number: NCT03100552.).

Two-stage endoscopic mucosal resection is a safe and effective salvage therapy after a failed single-session approach

Background and study aimsu2002Endoscopic mucosal resection (EMR) of laterally spreading colonic lesions ≥u200a20u200amm (LSLs) is ideally performed in a single session (ssEMR) and avoids surgery inu200a>u200a90u200a% of patients. We investigated whether a second attempt is safe or useful when ssEMR fails at a tertiary center. Patients and methodsu2002In 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. Resultsu2002A total of 1944 LSLs (median size 35u200amm) underwent EMR. ssEMR was unsuccessful in 127 lesions, 43 of which underwent tsEMR, with success in 36 (83.7u200a%). Compared with ssEMR, tsEMR lesions were larger (median size 50u200amm vs. 30 mm; Pu200a<u200a0.001), exhibited more submucosal fibrosis (Pu200a<u200a0.001), and histology was more often tubular adenoma and less often serrated (Pu200a=u200a0.005). Lesions mainly required tsEMR for nonlifting (41.9u200a%) or poor endoscopic access (37.2u200a%). Failure of tsEMR was predicted by larger LSL (Pu200a=u200a0.03). Safety was comparable to ssEMR. Of the 33 LSLs that underwent tsEMR for benign disease and completed first surveillance, 27 (81.8u200a%) avoided surgery to long term follow-up. Conclusionsu2002tsEMR 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).

The size, morphology, site, and access score predicts critical outcomes of endoscopic mucosal resection in the colon

BACKGROUNDnThe 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).nnnMETHODSnWe retrospectively applied SMSA to a prospectively collected multicenter database of large colonic laterally spreading lesions (LSLs) ≥u200a20u200amm 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.nnnRESULTSn2675 lesions in 2675 patients (52.6u200a% male) underwent EMR. Failed single-session EMR occurred in 124 LSLs (4.6u200a%) and was predicted by the SMSA score (Pu200a<u200a0.001). Intraprocedural and clinically significant postendoscopic bleeding was significantly less common for SMSA 2 LSLs (odds ratio [OR] 0.36, Pu200a<u200a0.001 and OR 0.23, Pu200a<u200a0.01) and SMSA 3 LSLs (OR 0.41, P u200a<u200a0.001 and OR 0.60, Pu200a=u200a0.05) compared with SMSA 4 lesions. Similarly, endoscopic recurrence at first surveillance was less likely among SMSA 2 (OR 0.19, Pu200a<u200a0.001) and SMSA 3 (OR 0.33, Pu200a<u200a0.001) lesions compared with SMSA 4 lesions. This also extended to second surveillance among SMSA 4 LSLs.nnnCONCLUSIONnSMSA 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.

Endoscopic mucosal resection of laterally spreading lesions around or involving the appendiceal orifice: technique, risk factors for failure, and outcomes of a tertiary referral cohort (with video)

BACKGROUND AND AIMSnEMR 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.nnnMETHODSnConsecutive LSLsxa0≥20xa0mm and PA-LSLsxa0≥10xa0mm 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.nnnRESULTSnThirty-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%, Pxa0< .001), and those that involved a greater percentage of the appendiceal orifice (AO) were less likely to be attempted (Pxa0= .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, Pxa0= .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.nnnCONCLUSIONSnEMR 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.).

The clinical significance and synchronous polyp burden of large (≥ 20 mm) sessile serrated polyps in patients without serrated polyposis syndrome

BACKGROUNDnSessile serrated polyps (SSPs) are important precursors of colorectal carcinoma and interval cancer. Large SSPs (≥u200a20u200amm) outside the definition of serrated polyposis syndrome (SPS) have not been studied in comparison with SPS. We aimed to describe the characteristics of patients with large SSPs in this context.nnnMETHODSnPatients with at least one SSP (≥u200a20u200amm) were eligible. Data from three consecutive colonoscopies were used to compare clinical and endoscopic characteristics in three patient groups: SPS, a solitary large SSP, and patients with at least two SSPs without fulfilling the criteria for SPS (oligo-SSP). Data on the diagnostic colonoscopy were collected retrospectively, whereas the remaining data was collected prospectively.nnnRESULTSn67/146 patients (45.9u200a%) had SPS, 53/146 (36.3u200a%) had a solitary SSP, and 26/146 (17.8u200a%) were categorized as oligo-SSP. Personal (16.4u200a%, 9.4u200a%, and 11.5u200a%, respectively) and family (17.9u200a%, 17.0u200a%, and 23.1u200a%, respectively) history of colorectal carcinoma did not differ significantly between groups. Polyp burden was greater in SPS compared with solitary SSP but was not different from oligo-SSP (advanced adenomas: SPS 32.8u200a% vs. solitary SSP 9.4u200a% [Pu200a=u200a0.002] vs. oligo-SSP 34.6u200a% [Pu200a=u200a0.87]; ≥u200a10 conventional adenomas: 11.9u200a% vs. 0u200a% [Pu200a=u200a0.01] vs. 3.8u200a% [Pu200a=u200a0.44], respectively). Dysplasia in large SSPs was frequent in all groups (41.1u200a% overall). SPS was recognized by referring endoscopists in only 9.0u200a% of cases.nnnCONCLUSIONnPatients with oligo-SSPs have similar synchronous polyp burden and clinical characteristics as patients with SPS and may require similar surveillance. Modification of the criteria for the diagnosis of SPS to include this group seems warranted. Patients with a solitary SSP have a lower risk of synchronous polyps, including advanced adenomas. Larger studies are warranted to determine whether these patients may return to standard surveillance following complete examination and clearance of the colon.

Traditional Serrated Adenomas: Not All Serrations Are the Same

Janssen; and obtained unrestricted research grant from AbbVie and MSD. H.Z. received honoraria for consulting and lecturing for AbbVie, Bristol Myer-Squibb, Gilead, Janssen, and MSD. A.M. is a member of the advisory boards AbbVie, MSD, Bristol Myer-Squibb, and Gilead; received speaker ́s honoraria from Bristol Myer-Squibb, Gilead, and AbbVie; and obtained unrestricted research grant from Roche, Gilead, and MSD. W.V. are the speakers of Bureau Gilead and Bristol Myer Squibb. I.G. is a member of the advisory boards AbbVie, BMS, MSD, Gilead, and Janssen; received speaker’s honoraria from Gilead, AbbVie, and MSD; and obtained travel grant from Gilead. M.G. is a advisor in MSD, BMS, Gilead, and GlaxoSmithKline Pharma; and received speaker honoraria from Roche Austria, Vertex/Tibotec, MSD, BMS, Gilead, and GlaxoSmithKline Pharma. K.K. received travel grants from Gilead, Abbvie, and BMS. C.F. received travel grants from Gilead and Janssen. P.F. is a member of the advisory boards AbbVie, MSD, Bristol Myer-Squibb, Gilead, and Roche; received speaker ́s honoraria from BMS, Gilead, AbbVie, and Roche; and obtained unrestricted research grant from Roche and Gilead. H.H. received lecture fees from AbbVie, MSD, Bristol Myer-Squibb,Gilead, and Janssen; obtained unrestricted research grant from AbbVie; is an advisory board member of AbbVie, MSD, Bristol Myer-Squibb, Gilead, and Janssen. Th e remaining authors declare no competing fi nancial interests.