Background
Determining the depth of invasion of early stage colorectal cancer has been emphasized as a means of improving endoscopic diagnostic accuracy. Recent studies have focused on other ...pathological risk factors for lymph node metastasis (LNM). We investigated the significance of depth of invasion and predictive properties of other endoscopic findings.
Methods
We retrospectively investigated 846 patients with submucosal invasive (T1) colorectal cancer who received an accurate pathological diagnosis and were treated between January 2005 and December 2016. Pathological risk factors associated with LNM were reviewed. We divided patients into groups: low-risk T1 colorectal cancer (LRC; no risk factors) and high-risk T1 colorectal cancer (HRC; exhibiting lymphovascular invasion, tumor budding grade of 2/3, and/or poor differentiation) and studied predictive endoscopic factors for HRC.
Results
Significant risk factors for LNM in multivariate analysis were lymphovascular invasion odds ratio (OR) 8.09; 95% confidence interval (CI) 3.84–17.1, tumor budding (OR 1.89; 95% CI 1.09–3.29), and histological differentiation (OR 2.09; 95% CI 1.12–3.89). The LNM-positive rate with only deep submucosal invasion was 1.6%. Significant predictive factors for HRC in multivariate analysis identified rectal tumor location (OR 1.92; 95% CI 1.35 –2.72, depression (OR 2.73; 95% CI 1.96 –3.80), protuberance within the depression (OR 2.58; 95% CI 1.39– 4.78), expansiveness (OR 2.39; 95% CI 1.27– 4.50), and loss of mucosal patterns (OR 1.90; 95% CI 1.20 –3.01) as significant factors.
Conclusions
Rectal tumor location, depression, protuberance within the depression, expansiveness, and loss of mucosal patterns could be predictive factors for HRC.
Radiation therapy is increasingly the first choice of treatment for pelvic malignancies such as prostate cancer and uterine cancer. However, radiation colitis is an acute or chronic side effect in ...the small and large bowels and includes hemorrhagic sigmoid proctitis, ulcer formation, stenosis and fistula. Bloody stool is the most frequent symptom of radiation proctitis (RP). We propose the following classification of RP in order to systematically perform treatment with argon plasma coagulation (APC): Type A, localized telangiectasia; Type B, diffuse telangiectasia; Type C, shallow ulcer or erosion with diffuse telangiectasia, major indication is active bleeding; and Type D, deep ulcer and remarkably fragile mucosa. Four points on the technique of APC treatment are as follows: Ⅰ, Spotting technique; Ⅱ, rinsing well with water to be able to recognize target vessels; Ⅲ, inverting the endoscope to look up the anal canal with a slim scope; Ⅳ, multi-session strategy. Starting from recognizing the classification according to the condition being treated, a long-term hemostatic effect can be obtained based on the treatment strategy, technique of the coagulation method, and judgment of its effect.
Background
Colorectal endoscopic submucosal dissection (ESD) requires advanced endoscopic skill. For safer and more reliable ESD implementation, various traction devices have been developed in recent ...years. The purpose of this research was to evaluate whether an ESD training program using a traction device (TD) would contribute to the improvement of trainees’ skill acquisition.
Methods
The differences in treatment outcomes and learning curves by the training program were compared before and after the introduction of TD (control group: January 2014 to March 2016; TD group: April 2016 to June 2018).
Results
A total of 316 patients were included in the analysis (TD group: 202 cases; control group: 114 cases). The number of cases required to achieve proficiency in ESD techniques was 10 in the TD group and 21 in the control group. Compared to the control group, the TD group had a significant advantage in ESD self-completion rate (73.8% vs. 58.8%), dissection speed (19.5 mm
2
/min vs. 15.9 mm
2
/min), en bloc resection rate (100% vs. 90%), and R0 resection rate (96% vs. 83%).
Conclusions
The rate of colorectal ESD self-completion by trainees improved immediately after the start of the training program using a traction device compared to the conventional method, and the dissection speed tended to increase linearly with ESD experience. We believe that ESD training using a traction device will help ESD techniques to be performed safely and reliably among trainees.
To determine the long-term outcomes after colorectal endoscopic submucosal dissection (ESD), we conducted a large, multicenter, prospective cohort trial with a 5-year observation period.
Between ...February 2013 and January 2015, we consecutively enrolled 1740 patients with 1814 colorectal epithelial neoplasms ≥20 mm who underwent ESD. Patients with noncurative resection (non-CR) lesions underwent additional radical surgery, as needed. After the initial treatment, intensive 5-year follow-up with planned multiple colonoscopies was conducted to identify metastatic and/or local recurrences. Primary outcomes were overall survival, disease-specific survival, and intestinal preservation rates. The rates of local recurrence and metachronous invasive cancer were evaluated as the secondary outcomes.
The 5-year overall survival, disease-specific survival, and intestinal preservation rates were 93.6%, 99.6%, and 88.6%, respectively. Patients with CR lesions had no metastatic occurrence, and patients with non-CR lesions had 4 metastatic occurrences. Kaplan–Meier curves revealed that overall survival and disease-specific survival rates were significantly higher in patients with CR lesions than in those with non-CR lesions (P > .001 and P = .009, respectively). Local recurrence occurred in only 8 lesions (0.5%), which were successfully resected by subsequent endoscopic treatment. Multiple logistic regression analyses revealed that piecemeal resection (hazard ratio, 8.19; 95% CI, 1.47–45.7; P = .02) and margin-positive resection (hazard ratio, 8.06; 95% CI, 1.76–37.0; P = .007) were significant independent predictors of local recurrence after colorectal ESD. Fifteen metachronous invasive cancers (1.0%) were identified during surveillance colonoscopy, most of which required surgical resection.
A favorable long-term prognosis indicates that ESD can be the standard treatment for large colorectal epithelial neoplasms. Clinical Trial Registration Number: UMIN000010136.
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Accurate histologic assessment facilitated by endoscopic submucosal dissection enables stratification of the risk of lymph node metastasis and determines the necessity of additional surgery, which may have led to a good long-term prognosis.
Although smaller circular staplers are easier to insert and less likely to involve the vagina and levator ani muscles when performing double stapling technique anastomosis, surgeons often consider ...that larger circular staplers would be safer in reducing the risk of postoperative anastomotic strictures.
This study aimed to investigate the safety of using 25-mm circular staplers compared with 28/29-mm staplers in the double stapling technique anastomosis regarding the development of anastomotic strictures and other complications.
This is a retrospective observational study.
This study was conducted at a single comprehensive cancer center.
Consecutive patients undergoing curative colorectal resection with double stapling technique anastomosis for stage I to III sigmoid colon and rectal cancer between 2013 and 2016 were included.
The incidence of anastomotic complications (strictures, leakage, and bleeding) was compared between the 25- and 28/29-mm circular staplers. Predictors for anastomotic strictures were investigated with multivariable logistic regression.
Small (25-mm) staplers were used in 186 (22.8%) of 815 eligible patients. The 25-mm staplers were associated with use in female patients, splenic flexure take down, high tie of the inferior mesenteric artery, and low anastomosis. Overall anastomotic complications (11.8% vs 13.7%, p = 0.51), strictures (5.9% vs 3.3%, p = 0.11), leakage (2.7% vs 3.8%, p = 0.47), and bleeding (4.8% vs 7.6%, p = 0.19) were not different between the 25- and 28/29-mm staplers. From multivariable logistic regression, independent predictors of anastomotic strictures included diverting ostomy and anastomotic leakage, but not small circular stapler use. Most of the 32 anastomotic strictures were successfully treated without surgical intervention (finger dilation, n = 25; endoscopic intervention, n = 5).
This was a single-center retrospective study.
Use of 25-mm circular staplers for double stapling technique anastomosis is safe and does not increase the risk of anastomotic strictures and other anastomotic complications in comparison with larger staplers. See Video Abstract at http://links.lww.com/DCR/B576.
ANTECEDENTES:Aunque las engrapadoras circulares más pequeñas son más fáciles de insertar y menos probable que involucren a la vagina y los músculos elevadores del ano, cuando se realiza una anastomosis con técnica de doble engrapado, frecuentemente los cirujanos consideran que las engrapadoras circulares más grandes, serían más seguras para disminuir los riesgos de estenosis anastomóticas postoperatorias.OBJETIVO:El estudio se dirigió para investigar la seguridad en el uso de engrapadoras circulares de 25 mm, en comparación con engrapadoras de 28/29 mm, en anastomosis con técnica de doble engrapado, en relación al desarrollo de estenosis anastomóticas y otras complicaciones.DISEÑO:Estudio observacional retrospectivo.AJUSTE:Centro oncológico integral único.PACIENTES:Se incluyeron pacientes consecutivos sometidos a resección colorrectal curativa, con anastomosis y técnica de doble engrapado, para cáncer de recto y colon sigmoide en estadios I-III entre 2013 y 2016.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon las incidencias de complicaciones anastomóticas (estenosis, fugas y sangrados) entre las engrapadoras circulares de 25 y 28/29 mm. Los predictores para estenosis anastomóticas se investigaron con regresión logística multivariable.RESULTADOS:Entre un total de 815 pacientes elegibles, se utilizaron engrapadoras de 25 mm en 186 (22,8%). Las engrapadoras de 25 mm se asociaron con el uso en pacientes femeninas, descenso del ángulo esplénico, ligadura alta de arteria mesentérica inferior y anastomosis baja. Complicaciones anastomóticas generales (11,8% vs. 13,7%, p = 0,51), estenosis (5,9% vs. 3,3%, p = 0,11), fugas (2,7% vs. 3,8%, p = 0,47) y sangrado (4,8% vs. 7,6%, p = 0,19). No hubo diferencia entre las engrapadoras de 25 y 28/29 mm. En la regresión logística multivariable, predictores independientes de estenosis anastomóticas incluyeron ostomía derivativa y fuga anastomótica, pero no incluyeron el uso de engrapadoras circulares pequeñas. La mayoría de las 32 estenosis anastomóticas se trataron con éxito sin intervención quirúrgica (dilatación del dedo, n = 25; intervención endoscópica, n = 5).LIMITACIONES:Fue un estudio retrospectivo de un solo centro.CONCLUSIONES:El uso de engrapadoras circulares de 25 mm para la anastomosis con técnica de doble engrapado, es seguro y no aumenta el riesgo de estenosis anastomóticas y de otras complicaciones anastomóticas, cuando son comparadas con engrapadoras más grandes. Consulte Video Resumen en http://links.lww.com/DCR/B576. (Traducción-Dr. Fidel Ruiz-Healy).
•Colorectal cancer metastasis can be predicted by morphology based machine learning.•Cytokeratin immunohistochemistry enables sufficient colorectal cancer foci detection.•Successful lymph node ...metastasis prediction can be achieved by random forest method.
Prediction of lymph node metastasis (LNM) for early colorectal cancer (CRC) is critical for determining treatment strategies after endoscopic resection. Some histologic parameters for predicting LNM have been established, but evaluator error and inter-observer disagreement are unsolved issues. Here we describe an LNM prediction algorithm for submucosal invasive (T1) CRC based on machine learning.
We conducted a retrospective single-institution study of 397 T1 CRCs. Several morphologic parameters were extracted from whole slide images of cytokeratin immunohistochemistry using Image J. A random forest algorithm for a training dataset (n = 277) was executed and used to predict LNM for the test dataset (n = 120). The results were compared with conventional histologic evaluation of hematoxylin-eosin staining.
Machine learning showed better LNM predictive ability than the conventional method on some datasets. Cross validation revealed no significant difference between the methods. Machine learning resulted in fewer false-negative cases than the conventional method.
Machine learning on whole slide images is a potential alternative for determining treatment strategies for T1 CRC.
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Total colectomy is the standard treatment for familial adenomatous polyposis (FAP). Recently, an increasing number of young patients with FAP have requested the postponement of surgery or have ...refused to undergo surgery. We aimed to evaluate the effectiveness of intensive endoscopic removal for downstaging of polyp burden (IDP) in FAP.
A single-arm intervention study was conducted at 22 facilities. Participants were patients with FAP, aged ≥ 16 years, who had not undergone colectomy or who had undergone colectomy but had ≥ 10 cm of large intestine remaining. For IDP, colorectal polyps of ≥ 10 mm were removed, followed by polyps of ≥ 5 mm. The primary end point was the presence/absence of colectomy during a 5-year intervention period.
222 patients were eligible, of whom 166 had not undergone colectomy, 46 had undergone subtotal colectomy with ileorectal anastomosis, and 10 had undergone partial resection of the large intestine. During the intervention period, five patients (2.3 %, 95 % confidence interval CI 0.74 %-5.18 %) underwent colectomy, and three patients died. Completion of the 5-year intervention period without colectomy was confirmed in 150 /166 patients who had not undergone colectomy (90.4 %, 95 %CI 84.8 %-94.4 %) and in 47 /56 patients who had previously undergone colectomy (83.9 %, 95 %CI 71.7 %-92.4 %).
IDP in patients with mild-to-moderate FAP could have the potential to be a useful means of preventing colorectal cancer without implementing colectomy. However, if the IDP protocol was proposed during a much longer term, it may not preclude the possibility that a large proportion of colectomies may still need to be performed.
Background
Serrated polyposis syndrome (SPS), a type of colorectal polyposis characterized by multiple serrated polyps, is associated with a high risk of colorectal carcinoma (CRC). This study aimed ...to clarify the clinicopathological characteristics of SPS in Japan.
Methods
We investigated the clinicopathological characteristics of patients with SPS from the “Multicenter Study on Clinicopathological Characteristics of SPS (UMIN 000032138)” by the Colorectal Serrated Polyposis Syndrome (SPS) Study Group. In this study, patients were diagnosed with SPS based on the 2019 World Health Organization (WHO) SPS diagnostic criteria.
Results
Ninety-four patients were diagnosed with SPS in 10 institutions between January 2001 and December 2017. The mean number (± standard deviation SD) of resected lesions per patient was 11.3 ± 13.8. The mean age at diagnosis of SPS was 63.3 ± 11.6 years, and 58 patients (61.7%) were male. Eighty-seven (92.6%) and 16 (17.0%) patients satisfied WHO diagnostic criteria I and II, respectively. Nine patients (9.6%) satisfied both criteria I and II. Carcinoma (T1–T4) were observed in 21 patients (22.3%) and 24 lesions. Of the 21 patients with CRC, 19 (90.4%) satisfied diagnostic criterion I, 1 (4.8%) satisfied diagnostic criterion II, and 1 (4.8%) satisfied diagnostic criteria I and II. There was no notable difference in the prevalence of CRC among patients who met diagnostic criterion I, II, and both I and II.
Conclusions
Patients with SPS have a high risk of CRC and should undergo regular surveillance colonoscopy. Raising awareness of this syndrome is crucial.
Background This study was performed to elucidate the etiology, effectiveness of diagnostic and therapeutic modalities, and outcomes in patients with acute lower gastrointestinal bleeding. Methods A ...retrospective review of the medical records of 1,112 consecutive patients admitted to the surgical service of a single urban emergency hospital with lower gastrointestinal bleeding from 1988 to 2006. Two groups were compared: 1988–1997 and 1998–2006. Results All patients underwent colonoscopy, 33.2% within 24 h of admission. Hematochezia was the most frequent presentation (55.5%), followed by maroon stool (16.7%) and melena (11.0%). Most patients, 690 (62.1%) also had upper endoscopy. Sixty-six patients subsequently had barium enemas. Eleven of 27 nuclide scans were positive. Arteriography was performed on 22 patients, with 11 positive results and 2 therapeutic. No statistical difference was found in procedures performed in our 2 time periods. Diverticulosis (33.5%), hemorrhoids (22.5%), and carcinoma (12.7%) were the most common etiologies with the diagnosis of diverticulosis more common in the 1998–2006 time period. The small bowel was the source in 14 total patients. Spontaneous cessation of the bleeding occurred in 863 (77.6%) patients. Endoscopic control increased from 1% in 1997–1998 to 4.4% in 1998–2006 ( P < .05) with a corresponding decrease in the need for operative control from 22.6% to 16.6% in this same time period ( P < .05). Furthermore, among elective operations, there was a decrease in right hemicolectomies from 31.6% of total elective cases to 13.9% ( P < .05). Emergent operations were needed in 3.4% and 4.8% of patients. The readmission rate did not change over time and was 5.2% overall with >50% because of diverticular bleeding. Conclusion In this urban setting, diverticulosis, hemorrhoids, and carcinoma were the most common causes of severe acute lower gastrointestinal bleeding (LGIB) with diverticular bleed causing the highest recurrence. Colonoscopy allows for diagnosis in most patients with severe acute LGIB requiring hospitalization. Furthermore, it is now being used more effectively for hemostasis resulting in less operative intervention to control bleeding.
Background
Colorectal endoscopic submucosal dissection (ESD) is technically demanding while ensuring safety, especially in cases with fibrosis and/or poor maneuverability. To overcome such ...difficulties, we developed a novel method called the pocket-creation method with a traction device (PCM with TD). We then evaluated the effectiveness and safety of PCM with TD in colorectal ESD compared to other conventional methods.
Methods
In total, 324 colorectal lesions treated with ESD from July 2018 to June 2019 were included. The following three treatment strategies were used: conventional ESD (CE), CE with TD, and PCM with TD. Patient backgrounds and treatment outcomes were retrospectively compared and analyzed.
Results
As ESD methods, CE, CE with TD, and PCM with TD account for 58% (187/324), 24% (78/324), and 18% (59/324), respectively. No significant difference was observed among the three groups in en bloc and R0 resection rates or adverse events. The rate of lesions with fibrosis and poor maneuverability was significantly higher in the PCM with TD group (CE group vs CE with TD group vs PCM with TD group: fibrosis, 24% vs 47% vs 64%,
p
< 0.001; poor maneuverability, 5.3% vs 13% vs 20%,
p
= 0.002). Dissection speed was significantly higher in the PCM with TD than in the CE with TD group (
p
= 0.003).
Conclusions
PCM with TD can achieve a stable en bloc resection rate and R0 dissection rate without adverse events even in the hands of trainees, irrespective of the size and location of the lesion, presence of fibrosis, and under poor maneuverability conditions.
