Nicholas J. Tutticci

Cold EMR of large sessile serrated polyps at colonoscopy (with video)

BACKGROUND AND AIMSnThe optimal technique for the resection of sessile serrated polyps (SSPs) is unknown, with established limitations and risks with conventional polypectomy. Although cold snare polypectomy is safe, the efficacy of piecemeal resection for large lesions is untested. In this study we evaluate the safety and efficacy of cold EMR for large SSPs.nnnMETHODSnPatients presenting for elective colonoscopy at an academic endoscopy center with 1 or more SSPsxa0≥10xa0mm in size were enrolled, excluding those on anticoagulant or antiplatelet therapy other than aspirin. Lesions were resected with a cold EMR technique comprising submucosal injection of succinylated gelatin and dilute methylene blue before piecemeal cold snare resection of all visible polyp with a margin of normal tissue.xa0Outcomes were the presence of residual serrated neoplasia in biopsy specimens from the defect margin and findings on surveillance colonoscopy.nnnRESULTSnCold EMR was performed on 163 SSPs during 105 procedures in 99 patients (97% women; median age, 57 years). The mean size was 17.5xa0mm: 61 SSPs werexa0≥20xa0mm and 13 SSPsxa0≥30xa0mm, and 97.5% were in the proximal colon. Cytologic dysplasia was present in 2 (1.2%). Margin biopsy specimens were positive in 2 lesions (1.2%). Surveillance colonoscopy for 82% of lesions (median, 5 months) showed residual serrated tissue in 1, treated with cold snare, but no evidence of recurrence in the remainder. Minor adverse events were seen in 3 patients; no delayed bleeding was observed.nnnCONCLUSIONSnCold EMR is a safe and effective method for the removal of large SSPs.

Patient acceptance of the optical diagnosis and misdiagnosis of diminutive colorectal polyps

BACKGROUND AND AIMSnOptical diagnosis allows for real-time endoscopic assessment of colorectal polyp histology and consists of the resect and discard and diagnose and leave paradigms. This survey assessed patient acceptance of optical diagnosis and their responses to a hypothetical doomsday scenario.nnnMETHODSnWe conducted a 3-month cross-sectional survey of colonoscopy outpatients presenting to an Australian academic endoscopy center.nnnRESULTSnA total of 981 patients completed the survey (76.0% response rate). The 60.8% of patients who supported resect and discard were more likely to be older men who co-supported diagnose and leave. Fewer patients (49.6%) supported diagnose and leave. A family history of missed cancer diagnosis (odds ratio [OR], 0.59; Pxa0=xa0.003) was significantly associated with rejection of resect and discard, and a personal or family history of bowel cancer (OR, 0.7; Pxa0= .04) was significantly associated with rejection of diagnose and leave. In the hypothetical scenario of a cancerous polyp incorrectly left in situ leading to stage III disease, 208 (21.2%) patients would definitely ask for financial compensation, 584 (59.5%) were unsure, and 189 (19.3%) would definitely not seek compensation. The patient-proposed median value of compensation sought was

Are proximal serrated polyps associated with clinical symptoms

760,000 USD (

The prevalence of sessile serrated adenomas in national bowel cancer screening program (NBCSP) participants

1,000,000 AUD;

Prevalence of serrated polyps: implications for significance as colorectal cancer precursors

1 AUD =

693 Cold Piecemeal Endoscopic Mucosal Resection (EMR) for Large Sessile Serrated Colonic Polyps

0.76 USD). Notably, 18.5% would be willing to give optical diagnosis another chance after this error.nnnCONCLUSIONnPatient support for optical diagnosis is limited, and those who are not supporters are more likely to seek financial compensation if errors occur.

High colonoscopic prevalence of sessile serrated adenomas in patients aged 40 years or less

Despite recognition of the significance of sessile serrated adenomas as precursor lesions in the serrated pathway to colorectal cancer [1,2] and the elevated risk of malignancy in serrated polyposis syndrome [3], little is known about the clinical features of colonic serrated polyps. Sessile serrated adenomas have been increasingly recognized in patients under 40 years of age [4]. The authors identified a group of five young patients with large proximal colonic serrated polyps found at colonoscopy undertaken to investigate symptoms of abdominal discomfort and loose frequent stools, within a private practice setting over a 12-month period. After failure of clinical consultation, blood and stool examination to determine a cause, all patients proceeded to endoscopy and colonoscopy under conscious sedation. As is the usual practice, routine biopsies were taken from the stomach, duodenum and right and left colon without cause for symptoms identified. At colonoscopy, all patients had at least one large, flat polyp in the proximal colon with a mucus cap identified; all visualized polyps were resected and retrieved for histopathological examination. All large flat proximal polyps were reported as serrated lesions (either hyperplastic polyp or sessile serrated adenoma). The patients were all female and aged 23 – 31 years of age without family history of colorectal cancer or of colonic polyps in first-degree relatives. All were of Caucasian background and only one was a current smoker. All patients described an improvement in diarrheal symptoms at first follow-up consultation without other interventions being instituted in the interim; however, two patients described recurrence of symptoms at subsequent review. The authors believe this small series raises the question of whether serrated colonic polyps are associated with clinical symptoms. In addition, the improvement in symptoms after polyp resection raises the possibility of a causal role. Further prospective studies which include a significant number of young patients undergoing colonoscopy for symptoms, a demographic which may be underrepresented in cohorts published to date, are required.

The prevalence and predictors of proximal serrated polyps in routine clinical practice: a prospective observational study

Diminutive” colonic polyps are by defi nition polyps that are 5 mm or less in size. Previous studies suggest that such polyps are of low risk for malignancy. However, improvements in optical imaging and image resolution (High Defi nition Endoscopy) coupled with increased operator awareness have resulted in a higher detection rate at colonoscopy. Past studies suggest that high grade dysplasia may occur up to a rate of 4% in these polyps. Methods Patients referred to a single Tertiary Institution for screening colonoscopy after detection of a positive FHH. All patients referred between 2009 and 2010 were included in this retrospective study. The patients were referred either through the National Bowel Cancer Screening Program or through GP initiated screening. Polyps were measured after the tissue was placed in formalin (histological size). For each colonoscopy the predetermined aim was to resect all polyps and to submit them to histological assessment. Results A total of 307 patients were investigated. NBCSP referred (41%) and GP initiated FOBT (59%). Male : Female (1.1:1). 148 (48%) patients showed a total of 258 polyps. 62% of polyps were size <5 mm, 22% were 5–9 mm and 16% were 10 mm or greater. The histological features of the polyps <5 mm were 56% tubular adenomas (TA), 7.5% were TVA and 0.6% were VA. Only 30% of polyps <5 mm were hyperplastic in nature. One TA showed high grade dysplasia (0.6%). No carcinoma was found in polyps <5 mm. A total of 11 (3.6%) carcinomas were identifi ed, 2/11 were in polyps >10 mm size and one in the 5–9 mm size. We also identifi ed the position of the polyp (<5 mm) according to left and right colonic classifi cation. 51% were left sided, 14%were right sided, location not specifi ed in 35%. Conclusion: In patients who are positive for FHH the incidence of diminutive polyps is considerable and importantly there is a signifi cant proportion of adenomatous polyps. Based on these fi ndings we believe that diminutive polyps should be resected and that they be followed up appropriately. Differences in bowel preparation for colonoscopy between ethnic groups S SETHI Bankstown Day Surgery, Sydney Introduction Suboptimal bowel preparation can result in missed lesions, aborted procedures and increases in cost and complication rates. The quality of bowel preparation can vary among patients depending on factors such as age, time of the day when colonoscopy is performed, literacy and inpatient status. There is a paucity of literature about the difference between ethnic groups in the quality of bowel preparation. Differences in literacy, diet and cultural factors may affect bowel preparation. The aim of this study was to determine whether the quality of bowel preparation differs among racial groups. Methods This was a retrospective study looking at 100 patients each undergoing colonoscopy from East Asia (China/Japan/South Korea/ Vietnam/Thailand), the Indian subcontinent (India/Bangladesh/Pakistan), United Kingdom, Southern Europe (Italy/Greece) and Arabic origin patients. Patients were contacted by telephone and classifi ed into an ethnic group. Patient related data was extracted from case notes. All patients were instructed to follow a standardized protocol of bowel preparation involving a low residue diet for 2 days and prep kit C the evening before the procedure. The quality of bowel preparation was graded by the endoscopist during the procedure and classifi ed as excellent, good, average or poor. These were then classifi ed as being either satisfactory (excellent/good) or unsatisfactory (average/poor). All were outpatients in a community day surgery setting and were performed in the morning. Results The groups did not differ signifi cantly in terms of age/sex. SATISFACTORY UNSATISFACTORY UNITED KINGDOM 87% 13% SOUTHERN EUROPE 84% 16% INDIAN SUBCONTINENT 76% 24% ASIAN 83% 17% ARABIC 81% 19% The Indian group had signifi cantly poorer bowel preparation as compared to the United Kingdom Group (p 0.002). There was no statistically signifi cant difference between the other groups. Discussion The poor bowel preparation of the Indian group may be due to factors such as poor English language profi ciency, diet and socioeconomic status. Hence, the Indian group may benefi t from more precise instructions and a more rigorous bowel preparation regime. Future studies should be performed to identify how ethnic factors affect bowel preparation. Journal of Gastroenterology and Hepatology (2011) 26 (Suppl. 4)