4486 Polypectomy of large polyps (= 2 cm): efficacy and safety.
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*4486 POLYPECTOMY OF LARGE POLYPS (≥ 2 cm): EFFICACY AND SAFETY. Enrique Vazquez-Sequeiros, Alex Geller, Nurit Geller, Christopher J. Gostout, Mayo Clin, Rochester, MN; Rabin Med Ctr, Petach-Tikva, Israel; Mayo Clin, Rochester, MI. Introduction: The potential for malignancy increases when adenomatous colonic polyps are larger than 2 cm. Many of these are amendable to endo- scopic removal. Aim: To assess long-term efficacy and safety of colonoscop- ic removal of large colonic polyps. Methods: Patients with large colonic polyps (> 2 cm), who underwent polypectomy were identified using the Mayo Biostatistics and GI database systems. Data obtained included: demographics, colonoscopy reports, polyp size and location, removal meth- ods, pathology, complications, subsequent procedures, and recurrence. Results: From May 1990 to March 1999, 287 pts underwent polypectomy for 320 large polyps. One hundred seventy eight (62%) were males. Mean age was 68±2.8 yrs (32-90). Mean polyp size was 2.79±0.94 cm (2-8). Polyp location was: cecum 31 (9.7%), ascending 62 (19.4%), hepatic flexure 24 (7.5%), transverse 22 (6.9%), splenic flexure 21 (6.6%), descending 23 (7.2%), sigmoid 98 (30.6%), and rectum 39 (12.2%). One hundred seventy five (54.7%) were sessile and 141 (44%) were pedunculated. Invasive car- cinoma was found in 13 polyps (4%). Four synchronous cancers (1.4%) were found, all distant to the index polyp. Initial follow-up colonoscopy after a median interval of 189 days in 138 pts (47%) revealed residual polyp at the index site in 69 (50%) which were retreated. Bleeding occurred in 6 pts (2%) with hospitalization over a mean of 8±8 days (2-30) with 1 requiring surgery.Two (0.6%) perforations occurred requiring surgery.Ten pts (3.4%) underwent surgery because of persistent polyp on follow-up colonoscopy (mean procedures 1.7±1.1, range 1-4). There was no procedure related mor- tality. Conclusions: 1. Polypectomy of large polyps is safe. 2. Colonoscopic removal of large polyps is desirable since only a small number (4%) of large polyps will contain invasive carcinoma. 3. Intensive follow-up with repeat- ed therapy is warranted because of a high residual polyp rate. *4487 A NOVEL APPROACH TO DETECTING COLORECTAL CANCERS: DIRECT IDENTIFICATION OF HISTOLOGY BY MAGNIFYING ENDOSCOPY. Shun-ichi Hayashi, Yoichi Ajioka, Yutaka Suzuki, Hajime Takeuchi, Masaki Azumaya, Atuo Nakamura, Masaaki Kobayashi, Terasu Honma, Rintarou Narisawa, Hitoshi Asakura, Niigata Rinkoh Gen Hosp, Niigata, Japan; Niigata Univ, Niigata, Japan; Third Dept of Internal Medicine, Niigata Univercity, Niigata, Japan; Niigata Univ Sch of Medicine, Niigata, Japan. Background: By magnifying endoscopic examination with dye spraying method, the openings of colonic glands, “pits” of various shapes and sizes, are found on the surface of colonic mucosa. In our data, pits of roundish, asteroid, tubular, and branching shape are seen on the surface of benign lesions. On the other hand, pits of irregular and complicated shapes can be seen on the surface of early cancers. Accordingly, it is important to clarify whether surface structure of colorectal cancer really reflects its histologi- cal findings. Aims: To examine whether complexity of pits revealed by magnifying endoscopic findings is correlated with that of histological find- ings, finding of the glandular structure and cellular atypia. Methods: 36 submucosal invasive cancers, 27 mucosal cancers, 40 adenomas and 10 specimens of normal mucosa were investigated. Pits of all lesions were examined by means of the magnifying video endoscope (Olympus, 240-Z) as well as the stereomicroscope after endoscopic or surgical removal. Histological sections were prepared from the area where pits of irregular shapes were located. Complexity of shapes of pits and histological glandu- lar structures were evaluated by fractal dimension (FD) with the box- counting method. In the present study irregular pits were morphologically classified into three types: irregularly roundish (IR), irregularly polygonal (IP) and irregularly branching (IB) pits. Results: 1) Fractal dimensions of pits were significantly correlated with those of glandular structures as revealed by the analysis of variance in regression (p<0.0001). 2) Fractal dimensions of (IR), (IP) and (IB) were 1.41±0.06, 1.66±0.09, and 1.61±0.05 respectively, all of which were higher than the values of benign lesions (p<0.001). 3)It was suggested that the high value of FD became the high cellular atypia became. Conclusions: Magnifying endoscopic findings are really correlated with histological atypia. Therefore, one of the most out- standing advantages of magnifying endoscopy lies in accurate detection of colorectal cancers without taking biopsy samples. It may be said that this will open up new vistas of detecting colorectal cancers especially at their early stages. *4488 RETROFLEXION IN LOWER GASTROINTESTINAL ENDOSCOPY. Shyam S. Varadarajulu, William H. Ramsey, Univ of Connecticut Health Ctr, Farmington, CT. Although recommended, RF to evaluate the rectal vault is not always prac- ticed in endoscopy. A previous study of 75 LGI endoscopies found that RF increased the diagnostic yield in distal rectum but a larger study of 453 subjects concluded that retroflex view (RV) did not produce additional information compared with straight view (SV) examination. Both studies did not detect any adenomatous polyps using this maneuver. This study was done to evaluate if RF increased the diagnostic yield compared with SV examination of the rectal vault. Methods: This prospective study included 600 consecutive patients undergoing diagnostic colonoscopy or flexible sigmoidoscopy. The rectal vault was first inspected carefully upon withdrawal of the endoscope. The scope was then readvanced into the rec- tum and retroflexed to view the vault. The scope was then straightened and a second look on SV at withdrawal was done. Endoscopic findings of the different views were noted. All polyps ≥ 5mm in size were biopsied. Results: The procedure was performed successfully in 592 patients (8 had contracted vault). Excluding internal hemorrhoids and polyps < 5mm, 30 patients had distinct lesions in the anorectum. Of the 9 adenomas detect- ed, 66% (6/9) were identified only on RF; all adenomas measured ≥ 1cm in size. More than 50% (16/30) of all lesions in the rectal vault were also observed only on RF. Three of 6 patients with adenomas in the rectal vault noted only on RF during sigmoidoscopy were found to have right sided ade- nomas on colonoscopy; the remaining 3 had no concomitant pathology. Conclusion: RF is safe and easy to perform. It increases diagnostic yield and can alter subsequent patient management. It is conceivable that a small anorectal lesion missed on screening can grow significantly in ≥ 5yr causing increased morbidity. Unless contraindicated, RF should be univer- sally practiced and emphasized in training as more nonphysicians are involved in performing sigmoidoscopy. Type of lesion RV only SV only Both views Hyperplastic Polyp 7 2 9 Tubular Adenoma 6 1 Villous Adenoma 0 2 Pseudopolyp 1 Ulcers/erosions 2 AB148 GASTROINTESTINAL ENDOSCOPY VOLUME 51, NO. 4, PART 2, 2000
Transcript of 4486 Polypectomy of large polyps (= 2 cm): efficacy and safety.
*4486POLYPECTOMY OF LARGE POLYPS (≥ 2 cm): EFFICACY ANDSAFETY.Enrique Vazquez-Sequeiros, Alex Geller, Nurit Geller, Christopher J.Gostout, Mayo Clin, Rochester, MN; Rabin Med Ctr, Petach-Tikva, Israel;Mayo Clin, Rochester, MI.Introduction: The potential for malignancy increases when adenomatouscolonic polyps are larger than 2 cm. Many of these are amendable to endo-scopic removal. Aim: To assess long-term efficacy and safety of colonoscop-ic removal of large colonic polyps. Methods: Patients with large colonicpolyps (> 2 cm), who underwent polypectomy were identified using theMayo Biostatistics and GI database systems. Data obtained included:demographics, colonoscopy reports, polyp size and location, removal meth-ods, pathology, complications, subsequent procedures, and recurrence.Results: From May 1990 to March 1999, 287 pts underwent polypectomyfor 320 large polyps. One hundred seventy eight (62%) were males. Meanage was 68±2.8 yrs (32-90). Mean polyp size was 2.79±0.94 cm (2-8). Polyplocation was: cecum 31 (9.7%), ascending 62 (19.4%), hepatic flexure 24(7.5%), transverse 22 (6.9%), splenic flexure 21 (6.6%), descending 23(7.2%), sigmoid 98 (30.6%), and rectum 39 (12.2%). One hundred seventyfive (54.7%) were sessile and 141 (44%) were pedunculated. Invasive car-cinoma was found in 13 polyps (4%). Four synchronous cancers (1.4%) werefound, all distant to the index polyp. Initial follow-up colonoscopy after amedian interval of 189 days in 138 pts (47%) revealed residual polyp at theindex site in 69 (50%) which were retreated. Bleeding occurred in 6 pts(2%) with hospitalization over a mean of 8±8 days (2-30) with 1 requiringsurgery. Two (0.6%) perforations occurred requiring surgery. Ten pts (3.4%)underwent surgery because of persistent polyp on follow-up colonoscopy(mean procedures 1.7±1.1, range 1-4). There was no procedure related mor-tality. Conclusions: 1. Polypectomy of large polyps is safe. 2. Colonoscopicremoval of large polyps is desirable since only a small number (4%) of largepolyps will contain invasive carcinoma. 3. Intensive follow-up with repeat-ed therapy is warranted because of a high residual polyp rate.
*4487A NOVEL APPROACH TO DETECTING COLORECTAL CANCERS:DIRECT IDENTIFICATION OF HISTOLOGY BY MAGNIFYINGENDOSCOPY.Shun-ichi Hayashi, Yoichi Ajioka, Yutaka Suzuki, Hajime Takeuchi,Masaki Azumaya, Atuo Nakamura, Masaaki Kobayashi, Terasu Honma,Rintarou Narisawa, Hitoshi Asakura, Niigata Rinkoh Gen Hosp, Niigata,Japan; Niigata Univ, Niigata, Japan; Third Dept of Internal Medicine,Niigata Univercity, Niigata, Japan; Niigata Univ Sch of Medicine, Niigata,Japan.Background: By magnifying endoscopic examination with dye sprayingmethod, the openings of colonic glands, “pits” of various shapes and sizes,are found on the surface of colonic mucosa. In our data, pits of roundish,asteroid, tubular, and branching shape are seen on the surface of benignlesions. On the other hand, pits of irregular and complicated shapes can beseen on the surface of early cancers. Accordingly, it is important to clarifywhether surface structure of colorectal cancer really reflects its histologi-cal findings. Aims: To examine whether complexity of pits revealed bymagnifying endoscopic findings is correlated with that of histological find-ings, finding of the glandular structure and cellular atypia. Methods: 36submucosal invasive cancers, 27 mucosal cancers, 40 adenomas and 10specimens of normal mucosa were investigated. Pits of all lesions wereexamined by means of the magnifying video endoscope (Olympus, 240-Z)as well as the stereomicroscope after endoscopic or surgical removal.Histological sections were prepared from the area where pits of irregularshapes were located. Complexity of shapes of pits and histological glandu-lar structures were evaluated by fractal dimension (FD) with the box-
counting method. In the present study irregular pits were morphologicallyclassified into three types: irregularly roundish (IR), irregularly polygonal(IP) and irregularly branching (IB) pits. Results: 1) Fractal dimensions ofpits were significantly correlated with those of glandular structures asrevealed by the analysis of variance in regression (p<0.0001). 2) Fractaldimensions of (IR), (IP) and (IB) were 1.41±0.06, 1.66±0.09, and 1.61±0.05respectively, all of which were higher than the values of benign lesions(p<0.001). 3)It was suggested that the high value of FD became the highcellular atypia became. Conclusions: Magnifying endoscopic findings arereally correlated with histological atypia. Therefore, one of the most out-standing advantages of magnifying endoscopy lies in accurate detection ofcolorectal cancers without taking biopsy samples. It may be said that thiswill open up new vistas of detecting colorectal cancers especially at theirearly stages.
*4488RETROFLEXION IN LOWER GASTROINTESTINAL ENDOSCOPY.Shyam S. Varadarajulu, William H. Ramsey, Univ of Connecticut HealthCtr, Farmington, CT.Although recommended, RF to evaluate the rectal vault is not always prac-ticed in endoscopy. A previous study of 75 LGI endoscopies found that RFincreased the diagnostic yield in distal rectum but a larger study of 453subjects concluded that retroflex view (RV) did not produce additionalinformation compared with straight view (SV) examination. Both studiesdid not detect any adenomatous polyps using this maneuver. This studywas done to evaluate if RF increased the diagnostic yield compared withSV examination of the rectal vault. Methods: This prospective studyincluded 600 consecutive patients undergoing diagnostic colonoscopy orflexible sigmoidoscopy. The rectal vault was first inspected carefully uponwithdrawal of the endoscope. The scope was then readvanced into the rec-tum and retroflexed to view the vault. The scope was then straightenedand a second look on SV at withdrawal was done. Endoscopic findings ofthe different views were noted. All polyps ≥ 5mm in size were biopsied.Results: The procedure was performed successfully in 592 patients (8 hadcontracted vault). Excluding internal hemorrhoids and polyps < 5mm, 30patients had distinct lesions in the anorectum. Of the 9 adenomas detect-ed, 66% (6/9) were identified only on RF; all adenomas measured ≥ 1cm insize. More than 50% (16/30) of all lesions in the rectal vault were alsoobserved only on RF. Three of 6 patients with adenomas in the rectal vaultnoted only on RF during sigmoidoscopy were found to have right sided ade-nomas on colonoscopy; the remaining 3 had no concomitant pathology.Conclusion: RF is safe and easy to perform. It increases diagnostic yieldand can alter subsequent patient management. It is conceivable that asmall anorectal lesion missed on screening can grow significantly in ≥ 5yrcausing increased morbidity. Unless contraindicated, RF should be univer-sally practiced and emphasized in training as more nonphysicians areinvolved in performing sigmoidoscopy.
Type of lesion RV only SV only Both views
Hyperplastic Polyp 7 2 9Tubular Adenoma 6 1Villous Adenoma 0 2Pseudopolyp 1Ulcers/erosions 2
AB148 GASTROINTESTINAL ENDOSCOPY VOLUME 51, NO. 4, PART 2, 2000
