Luke F. Hourigan

Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia.

BACKGROUND & AIMS 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.

Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study

Objective 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. Design 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. Results 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. Conclusions 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. Trial registration number: NCT01368289.

Endoscopic Resection for Barrett's High-Grade Dysplasia and Early Esophageal Adenocarcinoma: An Essential Staging Procedure With Long-Term Therapeutic Benefit

OBJECTIVES: Patients with Barretts high‐grade dysplasia (HGD) or early esophageal adenocarcinoma (EAC) that is shown on biopsy alone continue to undergo esophagectomy without more definitive histological staging. Endoscopic resection (ER) may provide more accurate histological grading and local tumor (T) staging, definitive therapy, and complete Barretts excision (CBE); however, long‐term outcome data are limited. Our objective was to demonstrate the effect on histological grade or local T stage, efficacy, safety and long‐term outcome of ER for Barretts HGD/EAC and of CBE in suitable patients. METHODS: This prospective study at two Australian academic hospitals involved 75 consecutive patients over 7 years undergoing ER for biopsy‐proven HGD or EAC, using multiband mucosectomy or cap technique. In addition, CBE by 2–3‐stage radical mucosectomy was attempted for all Barretts segments ≤3 cm in length in patients aged <75 years with minimal comorbidities. RESULTS: Biopsy histology showed HGD in 89% of patients and EAC in 11%. However, ER histology resulted in altered grading or staging in 48% of patients (down 28%, up 20%), with HGD in 53%, low‐grade dysplasia (LGD) in 19%, mucosal adenocarcinoma in 13%, submucosal adenocarcinoma in 9%, and no dysplasia in 4% of patients. The CBE success rate was 94%. Complications were one aspiration (hospitalization with full recovery) and six strictures successfully dilated endoscopically. During the mean follow‐up of 31 months (range 3–89), there was no recurrence at ER sites, 11% developed metachronous lesions and five patients underwent esophagectomy for ER‐demonstrated submucosal invasion. Esophagectomy specimens were T0N0M0 in three and T1N0M0 in two patients. There were no deaths due to adenocarcinoma. CONCLUSIONS: ER alters histological grade or local T stage in 48% of patients and dramatically reduces esophagectomy rates by providing safe and effective therapy. ER has a high success rate (94%) for CBE in short segment Barretts esophagus.

Impact of endoscopic intervention in 100 patients with suspected postcholecystectomy bile leak.

BACKGROUND Bile leak is a recognized complication of cholecystectomy. Endoscopic intervention is widely accepted as a treatment for this complication, but the optimal form is not well defined. METHODS An ERCP database was reviewed retrospectively to identify all cases of bile leak related to cholecystectomy. Patient records and endoscopy reports were reviewed, and structured telephone interviews were conducted to collect data. RESULTS A total of 100 patients (61 women, 39 men; mean age, 53 [17] years) with suspected postcholecystectomy bile leak were referred for ERCP. Cholecystectomy was commenced laparoscopically in 83 patients (with an open conversion rate of 30%). The most common symptoms were pain (n = 62) and fever (n = 37). Cholangiography was obtained in 96 patients. A leak was identified in 80/96 patients, the most common site being the cystic-duct stump (48), followed by ducts of Luschka (15), the T-tube site (7), and other sites (10). Treatment included stent insertion alone (40), sphincterotomy alone (18), combination stent/sphincterotomy (31), none (6), and other (1). Three patients with major bile-duct injuries were excluded from the analysis. Endoscopic therapy was unsuccessful in 7 patients (6 in the sphincterotomy alone group; p = 0.001). Four patients underwent surgery subsequent to ERCP to control the leak. All 4 were in the sphincterotomy alone group ( p = 0.001). Post-ERCP pancreatitis developed in 4 patients (3 mild, 1 moderate). CONCLUSIONS The optimal endoscopic intervention for postcholecystectomy bile leak should include temporary insertion of a biliary stent.

Risk Factors for Intraprocedural and Clinically Significant Delayed Bleeding After Wide-field Endoscopic Mucosal Resection of Large Colonic Lesions

BACKGROUND & AIMS 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.

Cost Analysis of Endoscopic Mucosal Resection vs Surgery for Large Laterally Spreading Colorectal Lesions

BACKGROUND & AIMS 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. METHODS 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. RESULTS 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

Endoscopic mucosal resection for large serrated lesions in comparison with adenomas: a prospective multicentre study of 2000 lesions

6,316,593 and total inpatient hospitalization length of stay was 1180 days. The total cost predicted for the surgical management group was US

Prophylactic Endoscopic Coagulation to Prevent Bleeding After Wide-Field Endoscopic Mucosal Resection of Large Sessile Colon Polyps

16,601,502, with a total inpatient hospitalization length of stay of 4986 days. Endoscopic management produced a potential total cost saving of US

Complete Barrett’s excision by stepwise endoscopic resection in short-segment disease: long term outcomes and predictors of stricture

10,284,909; the mean cost difference per patient was US

Clinical and endoscopic predictors of cytological dysplasia or cancer in a prospective multicentre study of large sessile serrated adenomas/polyps

7602 (95% confidence interval,