Abstracts

T1381

Diagnostic Yield of Water Enema Computed Tomography

(WECT) in First Line Investigation for Lower GI Bleeding in

Elderly PatientsStephane Nahon, Marie Lequoy, Huguette Houssard-Caugant,Cecile Poupardin, Vincent Jouannaud, Pierre Lahmek,Michel Cymbalista, Bruno LesgourguesBackground: Colonoscopy is not always easy to perform in elderly patientspresenting multiple comorbidities and treated by antiplatelet agents and/or vitaminK antagonists. Indeed, anesthesia, bowel preparation for colonoscopy and a stop ofantiplatelets agents or anticoagulant may compromise the cardiac prognosis. Aim:To evaluate the diagnostic yield of WECT in first line investigation for lower GIbleeding or iron-deficiency anemia in elderly patients with multiple comorbities.Method: From June 2007 and June 2008, we performed a WECT for iron-deficiencyanemia (nZ47), hematochezia (nZ29), a positive FOBT (nZ2) in 83 patients[47Female/36male, median age 81,2 yrs (65-94)]. They had at least one of thefollowing 3 criteria: 1) ischemic heart disease or atrial fibrillation, 2) treatment byantiplatelet agents and 3) treatment by vitamin K antagonist. An upper endoscopywas performed before WECT in order to rule out an upper GI lesion in case of iron-deficiency anemia. WECT was considered to be useful whether the diagnosis wasconfirmed by colonoscopy or was normal with a minimum follow-up of 6 monthswithout symptomatic recurrence. Results: WECT was exploitable at least partially in91% of the cases. No complication was observed. We noted ischemic heart disorderin 59% of the cases, hypertensive cardiopathy in 14%, hypertension in 39%, atrialfibrillation in 36%, a stroke in 14%, and cardiac valvulopathy in 7% of the cases. 52%of the patients took aspirin, 14% clopidrogel and 37% an anticoagulant. WECT wasincomplete in 7 cases, normal in 48 cases and pathological in 28 cases (table 1).Table 1 shows the concordance between the WECT and colonoscopy. WECT wasconsidered to be useful in 63% of the cases (21 diagnoses confirmed bycolonoscopy and 31 normal examinations without symptomatic relapse). In onecase, a cancer was diagnosed by colonoscopy while WECT was considered normal.Conclusion: WECT is a safe and a useful procedure in the elderly. In the situation oflower GI bleeding, WECTwas abnormal in 33% of cases showing a colorectal cancerin half of theses cases. wECT was considered to be useful in 63% of the cases.However, when the examination is normal, it is necessary to perform regularclinicobiological monitoring and a WECT or colonoscopy if the slightest doubtpersists.

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CANCER

NORMAL POLYP COLITIS NOT PERFORMED TOTAL

WECT

CANCER 13 0 0 0 2 15 NORMAL 1 0 0 0 47 48 POLYP 0 0 4 0 2 6 COLITIS 0 0 0 4 2 6

TOTAL

14 0 4 4 53 75

T1382

Do All Colorectal Polyps Require Pathological Examination?Bernard Denis, Anne Marie Weiss, Andre Peter, Gilles Breysacher,Pascale Chiappa, Isabelle Gendre, Philippe PerrinPathological examination of removed colorectal polyps places a huge burden onpathologists and represents a non negligible cost. It is of value only if clinicalmanagement is affected eg if colorectal cancer (CRC) is detected or if the post-polypectomy surveillance interval is guided. Aim: To assess whether it is possible toomit the pathological examination of some polyps without any risk for the patient.Methods: Retrospective assessment of all polyps removed from September 2003 toAugust 2008 within the organized gFOBT CRC screening program implemented inthe Haut-Rhin and prospective assessment of all polyps removed from January toAugust 2008 in a hospital endoscopy unit. Results: The results of the retrospectivestudy involving 4360 polyps are presented in the table. In the prospective study, 355polyps were removed during 175 colonoscopic procedures. 47.4% of them werea 1st procedure and 46.5% a surveillance procedure after surgery for CRC orpolypectomy. A family history of CRC was present in 13.9% of cases. 263 (74.1%)polyps were % 5 mm and 54 (15.2%) were R 10 mm. 90 (25.7%) polyps were nonadenomatous, 76 (21.4%) advanced adenoma and 2 (0.6%) invasive carcinoma. Thepathological examination was considered useful by the endoscopist for 148 (41.7%)polyps. This rate of useful examinations varied according to the polyps’ size (26.1%for polyps % 5 mm, 73.7% for 6-9 mm and 92.5% for R 10 mm)(p!0.001) and tothe context (57.1% in case of a 1st procedure and 23.4% in case of a surveillanceprocedure). The pathological examination was necessary for the determination ofthe surveillance interval in 24.0% of patients and modified the surveillance intervalproposed by the endoscopist in 8.6% of patients. It had no impact on thesurveillance interval in 67.4% of patients. If isolated polyps % 5 mm had not beenexamined in patients with either personal or family history of CRC or adenoma

: 2009

(37.5% of polyps in our prospective study) one patient out of 44 would have hada surveillance interval of 5 years instead of 3 years. Conclusion: Due to the risk ofinvasive carcinoma, all polyps O 5 mm require pathological examination. Thepathological examination of diminutive polyps % 5 mm either associated witha CRC or a polyp R 10 mm or removed in very old patients can be omitted withoutany risk for the patient. They represent 13.8% of polyps in a diversified recruitmentand 22.3% in an organized gFOBT CRC screening program.

polyps’ size % 5 mm 6 - 9 mm R 10 mm

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number n (%)

2351 (53.9) 630 (14.5) 1379 (31.6) invasive cancer n (%) 0 (0) 1 (0.2) 69 (5.0) advanced adenoma n (%) 280 (11.9) 177 (28.1) 1221 (88.5)

T1383

Endoscopic Mucosal Resection Versus Endoscopic Submucosal

Dissection According to the Sizes and the Subtypes of Laterally

Spreading TumorsDong Uk Kim, Geun-Am Song, Sun Mi Lee, Tae Oh Kim, Gwang Ha Kim,Jeong HeoBackground and Aims: Among colorectal neoplasms, laterally spreading tumors(LSTs) are superficially-growing tumors over 10mm in diameter that are nowincreasingly diagnosed. We analyzed the clinicopathologic characteristics and theoutcomes of endoscopic treatments according to the sizes and the subtypes ofLSTs. Patients and Methods: One hundred seventeen patients underwentendoscopic mucosal resection(EMR) or endoscopic submucosal dissection(ESD)according to the size and the subtypes of LSTs. Exclusion criteria for endoscopictreatments included a poorly-differentiated or undifferentiated adenocarcinoma inpretreatment diagnosis, or positive non-lifting sign during endoscopic treatments.One hundred twenty one LSTs were analyzed retrospectively. Following endoscopictreatments, 39 lesions with piecemeal resection or positive resection margin werefollowed at 6 and 12 months using total colonoscopy. Results: The most frequentlocation was the ascending colon(41.3%), followed by the rectum (24.8%).Morphologic types were granular homogenous (GH) types 28.9% (35/121), granularmixed nodular (MN) types 33.1% (40/121), non-granular flat elevated (FL) types19.8% (24/121), and non-granular psuedodepressed (PD) types 18.2% (22/121).Sixty eight LSTs (56.2%) were less than 20 mm in diameter, 28(23.1%) were 20w30mm, 14 (11.6%) were 30w40mm, and 11 (9.1%) were larger than 40 mm. ESD wasperformed in seven GH and two FL lesions more than 30mm in diameters, sixteenPD lesions more than 15mm, and twenty MN lesions including a large nodule morethan 10mm. Other 76 lesions were treated by EMR. The rates of en bloc resection inEMR and ESD were 72.4% (55/76) and 80% (36/45), and the complications includingmajor bleeding and perforation occurred at 3 of 76 and 3 of 45 lesions, respectively.The recurrent lesions were founded at 2 of 17 lesions treated by EMR and 1 of 21lesions by ESD. The overall malignancy rate was 19.8% (24/121). Malignancy rateswere 16.7% (16/96) in the lesions less than 30 mm, and 32% (8/25) in larger than 30mm. Malignancy rates were 2.8% (1/35) in GH type, 32.5% (13/40) in MN type, 8.3%(2/24) in FL type, and 36.3% (8/22) in PD type. Conclusions: LSTs larger than 30 mmhad high malignant potential. Furthermore, MN or PD type had higher malignantpotential than GH or FL type. There were no differences in the outcomes betweenEMR and ESD, if treatment modality were selected according to the sizes and thesubtypes of LSTs.

EMR ESD p-valve

urn

En bloc resection

55/76 (72.4%) 36/45 (80%) n.s. Recurrent lesions 2/17 (11.8%) 1/21 (4.8%) n.s. Complications 3/76 (3.9%) 3/45 (6.7%) n.s.

n.s.; no significant.

T1384

Impact of Colonoscopy in the Diagnosis and Management of

Diarrhea in Solid Organ Transplant RecipientsJohn Rice, Bret J. Spier, Daniel Cornett, Andrew J. Walker, Patrick PfauBackground: Diarrhea is common in solid organ transplant recipients with theincidence ranging from 13 to 43%. Colonoscopy with random biopsies is frequentlyperformed in the diagnostic evaluation of the post-transplant population withdiarrhea. Aim: To determine the yield of colonoscopy in the diagnosis andmanagement of diarrhea in the solid organ transplant recipient. Methods: FromOctober 1996 to June 2008, 88 patients were identified who had undergone solidorgan transplantation and subsequently underwent colonoscopy for an indicationof ‘‘diarrhea’’. Endoscopic findings at time of colonoscopy and any subsequentpathology were reviewed to determine the impact of these studies on themanagement of the patient’s diarrhea. Results: 88 patients (mean age 54 years, 65%

al.org

Abstracts

male) underwent colonoscopy a mean of 69 months after transplantation (31kidney, 26 liver, 21 heart, 6 kidney-pancreas, 3 lung, 1 lung-kidney, 1 pancreas).Stool studies including evaluation for clostridium difficile, ova and parasites andstool culture were performed in only 28.1% of patients prior to colonoscopy.Abnormal endoscopic findings were seen in 16/88 (18.2%). Pathology was abnormalin 17/80 (21.3%). In total, only 9/88 (10%) had findings on colonoscopy orpathology that led to a change in management for the diarrhea. Four of 9 patientsthat had a change in management had findings that could have been diagnosedwith flexible sigmoidoscopy. Therefore, overall only 6% (5/88) of all patients hadmanagement affected by colonoscopic investigation. There was 1 seriouscomplication (perforation) associated with colonoscopy. No difference incolonoscopy/pathology findings was seen based upon diarrhea duration (acute vs.chronic). Conclusion: The use of colonoscopy with biopsy in the evaluation of postsolid organ transplant recipients with diarrhea rarely shows pathologic disease andis unlikely to change patient management in the vast majority of cases. In theabsence of other indications, colonoscopy should be reserved for continueddiarrhea after negative stool studies and sigmoidoscopy.

T1385

Management of Colorectal Cancer Less Than 10mm in Diameter

On the Basis of Pit Pattern DiagnosisOrie Takemura, Shin-Ei Kudo, Hiroshi Kashida, Yoshiki Wada,Kunihiko Wakamura, Takemasa Hayashi, Toshihisa Hosoya,Hideyuki Miyachi, Yasutoshi Kobayashi, Nobunao Ikehara,Fuyuhiko Yamamura, Kazuo Ohtsuka, Shigeharu HamataniBackground and Aims: In most cases, small colorectal neoplasms can beendoscopically resected in one piece. However, we have recognized that somedepressed type neoplasms invade the submucosal layer when they are very small.Endoscopic mucosal resection (EMR) should be performed after the preciseprediction of the lesion depth. The aim of this study is to clarify the availability ofpit pattern diagnosis for small colorectal lesions and the significance of EMR asa means of excisional biopsy of the lesions. Methods: A total of 10212 colorectalneoplasms excluding advanced carcinomas were resected endoscopically orsurgically from Apr. 2001 to Jun. 2008 in our unit. Those less than 10mm indiameter amounting to 7258 lesions were included in the study. The morphologicand pathological findings of these small lesions were analyzed from our data files.Results: Among the subjective lesions, 4535 cases (62.5%) were protruded type,2651 cases (36.5%) and 72 cases (1.0%) were flat and depressed type lesions. Therates of submucosal invasion were 0.7% (30/4535) for protruded lesions, 0.2% (6/2651) for flat lesions and 45.8% (33/72) for protruded lesions. The difference inrates of submucosal invasion was significant (p!0.0001). Although depressedlesions are less frequent, they are characteristic for a high rate of submucosalinvasion. In other words, depressed lesions have high potential for invadingsubmucosal layer even when they are very small. As for the pit pattern of thelesions, type IIIL, IIIS, IV, VI and VN were recognized in 6070 (83.6%), 64 (0.9%), 961(13.2%), 147 (2.0%) and 16 (0.2%) lesions, respectively. The comparison betweenthe pit pattern and submucosal invasion showed that lesions with type IIIL, IIIS andIV were associated with very low rate (0.1%) of invasion. On the other hand, therespective rates of invasion in those with VI pit pattern and VN were 32.0% and87.5%. Lesions with VN pit pattern and depressed lesions with VI pit pattern shouldbe considered to be treated surgically because of their high rate of submucosalinvasion (87.5% and 62.5%). Protruded or flat lesions with VI pit pattern can betreated endoscopically as the possible invasion is usually only slight. Conclusion:The precision of pattern diagnosis is high enough for small lesions. In most cases,depressed lesions with VI pit pattern and/or lesions with VN pit pattern should betreated surgically even if they are less than 10mm in diameter.

T1386

New Conformable Uncovered Stent for Alternative Palliative

Treatment of Malignant Colorectal ObstructionJin Hong Kim, Jong Su Kim, Kee Myung Lee, Hyun Chul Lim, SungJae Shin, Kwang Jae Lee, Jae Chul Hwang, Soon Sun KimBackground: Self-expandable metallic stents (SEMS) relieve malignant colorectalobstruction and is used as a palliative treatment or as a bridge to surgery.Conventional uncovered stents are designed to be braided and shows significantforeshortening and relatively frequent migration. Recently a new conformableuncovered stent has been developed to prevent stent migration in malignantcolorectal obstruction. The aims of this study were to compare clinical effectbetween the new conformable uncovered stent and conventional uncovered stentfor the treatment of malignant colonic obstruction. Patients and Methods: FromJuly 1998 to August 2008, 79 patients (mean age: 62.1, sex ratio: 47: 32) withmalignant colorectal obstruction were assigned for uncovered stent placement (58conventional stents (Niti-S stent, Taewoong Medical Co., Goyang, Korea), 21conformable uncovered stents (D-type stent, Taewoong Medical Co., Goyang,Korea)). A D-type stent is a conformable uncovered stent with unfixed cells and hashigher flexibility and conformability. The stents were inserted for palliative orbridge therapy using the through-the-scope method. Data was analyzed on

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patients’ background, obstruction site, success rate, clinical efficacy, stent patencyperiod, and early and late complications. Results: success rate and clinical efficacywere not different between the conventional uncovered stent group and the D-typestent group (100% vs 95.2%; 89.6% vs 95%). In all of the enrolled patients, earlystent migration only occurred in the conventional stent group, and not the D-typestent group (10.3%; 0%). Analyzing only the palliative group, late stent migrationwas more frequent in the D-type stent group than the conventional stent group(20%; 0%). All of the late stent migration in the D-type stent group occurred afterconcomitant chemotherapy and radiotherapy, and obstructive symptoms didn’trecur after late stent migration. Conclusion: The new conformable uncovered stent,D-type stent shows no early migration in patients with malignant colorectalobstruction. However, late migration of the D-type stent in the palliative groupoccurred more frequently than in the conventional stent group, mainly afterconcomitant chemo-radiation therapy.

T1387

Correlation Between White Light Imaging and Autofluorescence

Imaging for Endoscopic Findings of Ulcerative ColitisTaro Osada, Naoto Sakamoto, Tomoyoshi Shibuya, Kazuko Beppu,Kenshi Matsumoto, Daisuke Asaoka, Akihito Nagahara, Michiro Otaka,Tatsuo Ogihara, Sumio WatanabeBackground and Aim: The diagnosis of ulcerative colitis (UC) has been facilitated bythe introduction of high resolution endoscopic imaging. Additionally, endoscopy isthe most convenient and objective method for assessing and quantifying intestinalmucosal damage. However, it has been reported that there is inter-observervariation, and variation depending on the observer’s experience level in theendoscopic assessment of UC. The aim of this study was to evaluate the correlationbetween White light imaging (WLI) and Autofluorescence imaging (AFI) pictures forendoscopic findings of ulcerative colitis. Method: We performed colonoscopyexaminations in 30 patients with UC using a CF-FH260AZL/I (Olympus Inc., TokyoJapan) and observed the same sites with WLI and AFI. A total of 408 endoscopicpictures, 204 each with WLI and AFI of the same sites were selected. WLI pictureswere assessed for overall mucosal inflammation using Matts endoscopic score andseven endoscopic features: ‘vascular pattern’, ‘erythema’, ‘edema’, ‘granularity’,‘erosions’, ‘ulcerations’ and ‘friability’, scored from 0 to 10 points. AFI pictures werescored for the rate of red, green and blue color components based on the RGBcolor model. Endoscopic scores of the same sites assessed with WLI and AFI werecompared. These images could be downloaded from the server in JPEG format withno loss of quality. The file size of the downloaded image was about 100 kilobytes,with a pixel array of 640 � 480 and 24-bit color. Results: The rate of green colorcomponent was more closely correlated with overall mucosal inflammation(rZ-0.58) than red (rZ0.48) and blue (rZ0.52) color components. The mean (SD)components of green color were: Matts grade (MG) 1 0.365 (0.030), MG2 0.343(0.039), MG3 0.327 (0.039) and MG4 0.300 (0.045). The values of greencomponents were significantly different between MG1 and MG2, and between MG2and MG3 (p!0.05). The correlations of ‘vascular pattern’(rZ-0.59) and ‘edema’(rZ-0.55) scores on WLI were high with green components on AFI, but low with‘ulcerations’(rZ-0.20). Colonic mucosa appearing as almost normal on WLIappeared as a green color on AFI, and mucosa appearing as a decreased vascularpattern and as edema on WLI appeared as a gray color, with decreased greencomponents on AFI. Severe mucosal inflammation on WLI appeared as a deep gray(dark magenta) color on AFI, which may lead to decreased autofluorescence in thelesion. Conclusions: We conclude that AFI is a useful and objective method for thedetection of inflammatory regions and the degree of inflammatory change, which ismanifested by green color in the colonic mucosa in UC.

T1388

Retrospective Comparison Between Endoscopic Mucosal

Resection and Endoscopic Submucosal Dissection for Large

Colorectal TumorsNozomu Kobayashi, Santa Hattori, Hiroyoshi Kurihara, Naoto Yoshitake,Kiyotaka Umeki, Ryuzo SekiguchiBackground and Aims: Endoscopic submucosal dissection (ESD) was developed foren bloc resection of early gastric cancers, and applied to the colorectum. While itachieved high en bloc resection rate, a high complication rate, such as perforation,has also been reported. The aim of this study was to evaluate the effectiveness ofESD for large colorectal tumors in comparison with conventional endoscopicmucosal resection (EMR), retrospectively. Patients and Methods: Between January2000 and June 2007, a total of 27 colorectal tumors R20 mm in 27 patients wereresected by ESD, and 120 colorectal tumors measuring R20 mm in 197 patientswere resected by EMR. En bloc resection, complication and recurrence rates werecompared between two groups. Results: The mean size of the lesions was 33.0 mm(20-80) in the ESD group and 27.7mm (20-60) in the EMR group. En bloc resectionrates of ESD and EMR were 81.5% (22/27) and 28.3% (34/120), respectively. Therates of bleeding after ESD and EMR were 3.7% (1/27) and 2.5% (3/120),respectively. The rates of perforation during or after ESD and EMR were 14.8%(4/27) and 0.8% (1/120), respectively. Although, en bloc resection rate was

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