Introduction

There is controversy about the management of low-risk pT1 CRCs resected in piecemeal, due to impossibility in assessing margins and potential suboptimal histological risk stratification in a fragmented and cauterized specimen.

Aims & Methods

Aims:To compare en bloc and piecemeal resected low-risk pT1CRC in terms of overall survival (OS) and metastasis free survival (MFS).
Materials and Methods: Low risk pT1 CRCs (no poor differentiation and no lymphovascular invasion) either piecemeal or en bloc resected were selected from two combined European multicenter cohorts (EpiT1 Consortium and Dutch pT1CRC study group). The exclusion criteria were primary surgical treatment, incomplete local resection, lack of information on type of resection , lack of follow-up of at least 2 years. The outcomes studied were metastasis free survival(MFS) and overal survival(OS). Cox regression analysis was performed adjusting for rectal location, size, and pedunculated morphology.

Results

Results: 3918/7043 patients with a pT1 CRC met the inclusion criteria: 822 (21%) resected in piecemeal and 3096 (79%) resected en bloc (Table 1). After local treatment, 46.6% in the piecemeal group received completion oncological surgery and 26.6% in the en bloc group. Adjusted 5-yrs MFS was lower for the piecemeal resected pT1 CRCs (94.6% (95%CI) vs. en bloc 97.4% (95%CI);p=0.001). Within the piecemeal resected pT1CRC group, the adjusted 5-yrs MFS did not differ between the group which underwent completion surgery versus the group who received only surveillance. (93.7%(95%CI) vs 96.3% (95%CI), p=0.08). Patients with a pT1 CRC resected in piecemeal followed by secondary surgery showed more endoluminal recurrence than en bloc resected pT1 CRCs followed by surveillance (10.8% VS 1.6%, p<0.00), higher proportion of distant metastasis (13/381 (3.4%) vs 14/730 (1.9%), p = 0.04) despite a similar 5-yrs MFS (96.3% vs 97.8%, p=0.08).

TABLE 1. Baseline characteristics of the patients (Multivariate analysis)

Conclusion

Conclusions: Even after secondary surgery Piecemeal resected pT1 CRC have a worse outcome than en bloc resected pT1 CRCs with surveillance . This is probably due to suboptimal histological risk stratification in a fragmented and cauterized specimen.

Introduction

Radiofrequency ablation is considered the standard therapy for flat dysplastic BE. Hybrid APC is a newer under evaluation, less expensive technique, but with the need of a special injection device and catheter. Aim of the study: To evaluate the efficacy of a standard APC catheter after submucosal injection for BE ablation.

Aims & Methods

To evaluate the efficacy of a standard APC catheter after submucosal injection for BE ablation. Naïve or after previous treatments patients with BE and low - grade dysplasia (LGD) were prospectively evaluated. Sodium chloride solution 0.9% was injected submucosally with a 23 G needle followed by APC application with a standard catheter (ERBE APC 300, 45Watts) on the created cushion. The same procedure was repeated for most of BE surface to be cauterized, with special attention not to ablate large circumferential areas. Patients were under high dose PPIs. Biopsies were taken according to the Seattle protocol during the follow-up.

Results

31 patients, 28 males (90.3%), 56.7±12.5 years old. Their initial diagnosis was: 19 patients with LGD (61.3%), 7 with high grade dysplasia (22.6%), and 5 with intramucosal cancer (16.1%). Eleven patients (35.5%) had previous endoscopic mucosal resection (EMR) while 7 (22.6%) had received radiofrequency ablation (RFA). Median BE length with LGD at the beginning of APC was 4cm (25th-75th:2-7, min-max:1-10). Median follow-up:10.1(1-108) months. In total 20 (64.5%) patients completely eradicated BE. For the remaining 11 patients APC led to a substantial reduction of BE length [Initial Median: C3M6 (Min: C0M1, Max: C6M8) to a final median: C0M2 (Min:C0M1, Max:C2M5] but the study is ongoing. Initial BE length was correlated to APC sessions needed (r= 0.54, p<0.01) but was not a limiting factor for complete BE eradication. Instead, smoking was an aggravating factor for BE complete eradication (HR=3.12, 95%CI.: 1.2-8.12, p=0.02). No death, hospitalization, severe hemorrhage, or perforation were observed. In 7 patients moderate pain requiring paracetamol, resolved after a few hours of in hospital supervision while 11 patients had mild dysphagia the following days without permanent stenosis.

Conclusion

Conclusions: 1) Standard APC after submucosal injection is safe and tolerable for BE ablation. 2) It may be applied in naïve patients or if other techniques were previously used. 3) Length increases the number of sessions needed but does not seem to be a limiting factor for APC application.

Introduction

The treatment of symptomatic hemorrhoidal disease (HD) in patients with bleeding disorders (BD) is challenging. This vulnerable group benefits the most from less invasive office-based procedures associated with low bleeding complications, namely polidocanol foam sclerotherapy (PFS).

Aims & Methods

The present study aimed to compare the efficacy and safety of polidocanol foam sclerotherapy (PFS) in the treatment of hemorrhoidal disease (HD) in patients with and without bleeding disorders (BD).
This was a prospective, multicentric, cohort study that enrolled patients with symptomatic internal HD grades I-III with BD (group B) and without BD (group A) following a 18-months period. HD baseline severity was assessed using the Goligher classification, the hemorrhoidal disease bleeding grade (HDBG) and the Sodergren hemorrhoid symptom severity (SHSS) scoring system. Both groups were treated with PFS prepared according to the Tessari´s technique. Patients with congenital BD did not perform prior bleeding prophylaxis and patients with acquired BD due to antithrombotic drugs did not discontinue therapy. The efficacy outcomes included therapeutic success (defined by an improvement of HDBG and SHSS score over baseline) and recurrence of HD (defined by HDBG and SHSS score greater than at the end of the intervention period) during a 12-months follow-up period. The safety outcomes comprised the rate and severity of complications related to PFS.

Results

The study included 228 patients (Group A: 155; Group B: 73). At baseline, the group B presented higher HDBG (p<0.001) and SHSS (p=0.019). The overall therapeutic success rate was 93.4% with an average number of sessions of 1.51±0.74, significantly higher for group B (1.68±0.86 vs 1.43±0.65, p=0.013). A 11.4% complications rate was reported, the majority were mild (96.2%); bleeding complications occurred in 4.8% of the patients. No significant differences were reported between the two groups concerning therapeutic success, recurrence rate, and complications rate.

Conclusion

Patients with BD may present with more symptomatic HD at baseline. Nevertheless, PFS decreased hemorrhoidal bleeding and symptom severity with low incidence of complications in these patients, demonstrating similar effectiveness and safety comparing to patients without BD. Notably, performing PFS did not expose patients with BD to an increased thrombotic risk.

Introduction

Adequacy of bowel preparation (ABP) directly affects colonoscopy performance and adenoma detection rate. Studies attributed a role to the dosing regimen of the bowel cleansing agent, social and economic factors and comorbidities. However, data on the impact of kidney failure and renal replacement therapy (RRT) are lacking.

Aims & Methods

This study investigated how ABP compares between patients on RRT and age-matched subjects with normal kidney function.
All patients on RRT undergoing an elective colonoscopy between January 2016 and December 2021 were identified from the medical records of a university hospital, and matched to 2 closest age controls undergoing colonoscopy at the same date ± 7 days. Study subjects and controls were compared for demographics, comorbidities including history of abdominal surgery, use of bowel transit-influencing drugs, residential care stay and colonoscopy-related data (bowel preparation regimen, sedation type, colonoscopy findings, ABP defined as a cumulative Bristol Bowel Preparation Score >= 6 and a score of >= 2 for each colon segment). Statistical significant contributors to ABP were assessed by logistic regression.

Results

Ninety-one patients on RRT (76 on haemodialysis and 15 on peritoneal dialysis) and 182 controls were identified. Patients on RRT were older (69±12 vs. 64±14y, p=.008) and less frequently women (34% vs. 50%, p=.013). They had more diabetes (40% vs. 24%, p=.008), more history of abdominal surgery (32% vs. 21%, p=.047) and took more bowel transit-influencing drugs (50% vs. 28%, p<.0001). Bowel preparation regimens were equally distributed between both groups. There was no difference in the rate of ABP between groups (87% vs. 81%, p=NS). Logistic regression analysis did not reveal an association between RRT and ABP. ABP was negatively influenced by residency in residential care, overnight stay in the hospital before colonoscopy, history of central nervous system disease, and positively by split-dose regimen (Nagelkerke R square 0.329, p=<.001).

Conclusion

Despite less favourable associated conditions, ABP in RRT patients remains comparable to controls. Split-dose regimen, neurological conditions and in-hospital stay are significant predictors of adequate bowel preparation.

References

Clark BT, Rustagi T, Laine L. What level of bowel prep quality requires early repeat colonoscopy: systematic review and meta-analysis of the impact of preparation quality on adenoma detection rate. Am J Gastroenterol. 2014;109(11):1714-23; quiz 24.
Hassan C, East J, Radaelli F, Spada C, Benamouzig R, Bisschops R, et al. Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2019. Endoscopy. 2019;51(8):775-94.
Saumoy M, Jesudian AB, Aden B, Serur D, Sundararajan S, Sivananthan G, et al. High prevalence of colon adenomas in end-stage kidney disease patients on hemodialysis undergoing renal transplant evaluation. Clin Transplant. 2016;30(3):256-62.
24. Calderwood AH, Schroy PC, 3rd, Lieberman DA, Logan JR, Zurfluh M, Jacobson BC. Boston Bowel Preparation Scale scores provide a standardized definition of adequate for describing bowel cleanliness. Gastrointest Endosc. 2014;80(2):269-76.
25. Clark BT, Protiva P, Nagar A, Imaeda A, Ciarleglio MM, Deng Y, et al. Quantification of Adequate Bowel Preparation for Screening or Surveillance Colonoscopy in Men. Gastroenterology. 2016;150(2):396-405; quiz e14-5.
artel M, Barkun AN, Menard C, Restellini S, Kherad O, Vanasse A. Split-Dose Preparations Are Superior to Day-Before Bowel Cleansing Regimens: A Meta-analysis. Gastroenterology. 2015;149(1):79-88

Introduction

The current gold standard for diagnosis of Inflammatory bowel disease (IBD) is based on clinical and endoscopic evaluation as well as histologic and radiologic evaluation. However, endoscopic evaluation can be uncomfortable and carry some risks, especially in the pediatric population that requires general anesthesia in order to perform the procedure.

Aims & Methods

Our aim was to investigate whether serum biomarkers can differentiate between pediatric patients with and without IBD. Secondary aims were to determine whether there are biomarkers that can differentiate between Crohn's disease (CD) and Ulcerative colitis (UC), and whether we can predict progression to biologic treatment within one year from diagnosis using these biomarkers.
Pediatric patients undergoing a first diagnostic colonoscopy at British Columbia Children's Hospital (BCCH) between December 2019 and June 2022 were invited to participate in the study. A 2 ml blood sample was taken from each participant at the time of colonoscopy. Demographic and clinical data were collected from each patient. Blood samples were analyzed using the Legendplex^TM flow cytometry kits investigating which included 50 different inflammatory cytokines and chemokines associated with IBD. A prediction model was built via a supervised learning method to determine how well we can predict the different groups.

Results

One hundred pediatric patients participated in the initial study. Five were excluded from the analysis due to uncertain diagnosis. Median age was 13.36 years, 39 were females (41%) and 54 (56.84%) were diagnosed with IBD, with 35 (64.81%) diagnosed with Crohn's disease. On a univariate analysis and Volcano plot 6 biomarkers were found to be strongly associated with the diagnosis of IBD: IL22, IL8, TARC, GROA, MIG, and IL18. The cross-validated AUROC was 0.70. Using SPLS-DA the classification accuracy was improved to 0.84, and MIG was found to be the key biomarker to discriminate between pediatric IBD patients and non-IBD patients.
On a univariate analysis only TSLP was found statistically significant as a predictor of CD, and RANTES and TARC were found as negative predictors for initiating biologic treatment within one year of diagnosis. However, the prediction model did not predict well the subclasses nor progression to biologic treatment.

Conclusion

Using serum biomarkers can predict the diagnosis of Pediatric IBD. MIG was found to be the key biomarker in the prediction model.