Introduction

Endoscopic recognition of malignant colorectal polyps is challenging, as most do not exhibit obvious signs of submucosal invasion, despite advancements in optical diagnostic techniques. While endoscopic resection might achieve cure, comprehensive data on cure rates and predictive factors are lacking.

Aims & Methods

This study aimed to elucidate the endoscopic predictors associated with achieving cure for malignant polyps. We conducted a retrospective analysis of electronic medical records for patients undergoing colonoscopy with endoscopic mucosal resection at our institution. Patients with confirmed colorectal adenocarcinoma classified as stage T1 were included and those with biopsied and tattooed polyps referred for surgery were excluded. Data regarding polyp size, morphology, location, and indirect signs of submucosal invasion (non-lifting sign; chicken-skin sign; edge retraction; depressed areas; fold convergence; ulceration) were collected. Endoscopic cure was defined by negative margins (>1mm) and favorable histological prognosis factors.

Results

A total of 165 patients were included, 57.6% males, with a mean age of 65 years. A total of 170 malignant polyps were resected with a global cure rate of 33.5%. Pedunculated polyps accounted for 37.1% and exhibited a significant association with endoscopic cure (p<0.001, OR 3.4, 95%CI 1.74-6.6) compared to nonpedunculated polyps (Paris classification 0-Is, any 0-II). Most pedunculated polyps were localized in the left colon (87.3%), and 50.8% were resected with cure. Interestingly, neither a large (p=0.532) nor a short stalk (p=0.672) nor polyp size (p=0.308) impacted the likelihood of cure. In contrast, the cure rate for nonpedunculated polyps was 23.4%. The distribution of nonpedunculated polyps was 38.3% in the rectum, 43.9% in the left colon, and 17.8% in the right colon. A “piecemeal” endoscopic resection (p<0.001), the presence of indirect signs of submucosal invasion (p<0.001) and size (cure: 19.8±7.4mm, no cure 26.4±12mm, p=0.01) were associated with non-curative resections. However, on multivariate analysis, only en-bloc resection emerged as an independent factor associated with cure (P=0.02, OR 5.6, 95% CI 1.3-24).

Conclusion

Our data underscores endoscopic resection viability for potentially malignant pediculated polyps, irrespective of size or stalk type. However, sessile/flat polyps present challenges, particularly when large or with endoscopic signs of submucosal invasion. In these scenarios, en-bloc removal using advanced techniques might contribute to better outcomes.

References

Saraiva S. Colorectal malignant polyps: a modern approach. Ann Gastroenterol. Published online 2021. doi:10.20524/aog.2021.0681
Shaukat A, Kaltenbach T, Dominitz JA, et al. Endoscopic Recognition and Management Strategies for Malignant Colorectal Polyps: Recommendations of the US Multi-Society Task Force on Colorectal Cancer. Off J Am Coll Gastroenterol ACG. 2020;115(11):1751. doi:10.14309/ajg.0000000000001013

Introduction

Renal dysfunction in the presence of end stage liver disease (ESLD) has been associated with increased morbidity and mortality post liver transplant (LT). In the presence of concomitant renal disease, pre-LT renal replacement therapy (RRT) has demonstrated improved outcomes post-LT. However, the role of RRT prior to LT in patients without renal disease is arguable.

Aims & Methods

In this study, we aimed to study the outcomes of RRT initiated pre-LT in patients awaiting LT without renal disease. US nationwide readmission database (NRD 2016 to 2019) was used. Hospitalizations that underwent RRT before liver transplant (cases) were identified using the database. A matched comparison cohort of similar hospitalizations who did not undergo RRT before liver transplant (controls) was identified from NRD after 1:1 propensity score matching.
After identifying the index admission from NRD, we calculated the time to RRT and time to LT using procedure codes and study patients were included only if time to RRT was less than time to LT, thereby correctly identifying patients who had RRT pre-LT. Inpatient clinical outcomes, mortality and survival estimates were calculated and compared. Hospitalizations with age<18 years, end-stage renal disease (ESRD) or CKD stage IV, renal transplant were excluded from the analysis.

Results

728 patients were included. We matched 364 hospitalizations with RRT before LT (cases) to 364 hospitalizations with no RRT before LT (controls). Adequate comorbidity balance was achieved with propensity matching between the comparison groups, including CKD (stage I - III), obesity, fluid & electrolyte disorder. The median age was 51.5 years in cases (IQR 43-59) and 54 years in controls (IQR 46-61). The time to liver transplant was longer in patients with pre-LT RRT as compared to no RRT before LT [13.5 days (IQR 8-20) vs 1 day (IQR 0-8), P<0.001].
There was no statistical difference in all-cause inpatient mortality between cases and controls (4.9% vs. 3.6%, P=0.4). Pre-LT RRT was associated with longer length of stay, 32 days (IQR 22-46) compared to 14 days (IQR 9-30) (P<0.001) in patients without pre-LT RRT. Additionally, the median total hospital charges were also higher in pre-LT RRT [$827,695 (IQR 574,184-1,354,623) vs $467,809 (IQR 323,809-724,291), P<0.001].
A significantly greater proportion of patients with RRT prior to LT were associated with mechanical ventilation (43.7% vs. 16.2%, OR 4.0 [2.8- 5.7], P<0.001), septic shock (44.8% vs. 21.4%, OR 2.9 [2.1- 4.1], P<0.001), ICU admission (40.7% vs. 17.0%, OR 3.3 [2.4- 4.7], P<0.001), vasopressor requirement (23.9% vs. 14.3%, OR 1.9 [1.3 - 2.8], P<0.001) and acute kidney injury (95.6% vs. 75.8%, OR 6.9 [3.9 - 12.1], P <0.001) as compared to controls. RRT requirement post LT was significantly greater in cases vs controls (100% vs 17%, P<0.001).
There was no difference in transplant rejection (5.2% vs 6%, p=0.6), risk of inpatient mortality at 30-day (HR 1.06 [0.4-2.6], P=0.9), 60-day (HR 0.85 [0.4-1.8], P=0.7) or 90-day intervals (HR 0.79 [0.4-1.6], P=0.5) (Figure 2) between the groups. 180-days Kaplan-Meier survival estimates were comparable as well (P=0.5).

Conclusion

Based on this study, RRT prior to LT was associated with greater instances of ICU related treatment, AKI and need for RRT post-LT. LT rejection, 30-day, 60-day and 90-day inpatient mortality were similar, along with comparable 180-day survival estimates. Results seem to suggest RRT is better avoided in pre-LT setting in the absence of renal dysfunction. Longitudinal studies are warranted to establish causality.

Introduction

The passive bending colonoscope (PBCS) has a passive bending section on the scope head that could make the scope advance deeply and smoothly without forming a walking-stick handle. Although the efficacy of PBCS as colonoscope has been presented^1-3, the utility in endoscopic retrograde cholangiopancreatography (ERCP) for the patients with surgically altered anatomy (SAA) has not been established. There is no large-scale studies exist to date and only a case series that described the effect of PBCS-ERCP for patients with SAA was reported⁴.

Aims & Methods

We performed a multicenter observational study to evaluate the outcome of PBCS-ERCP compared to balloon assisted enteroscope (BAE) ERCP that could expand the drainage options for SAA cases. This study involved 343 patients with SAA who underwent ERCP. Among them, 110 underwent PBCS-ERCP, while 233 underwent BAE-ERCP. Propensity score matching was applied and a final cohort of 210 (105 in each group) with well-balanced backgrounds (type of SAA, presence of stomach, presence of naïve papilla Vater, Age and sex) was analyzed. In this study, CF HQ290ZI (similar to CF-HQ190I) and PCF PQ260L (similar to PF-PH190L) (Olympus Medical Systems, Tokyo, Japan) were used as PBCS. As BAE, EI580BT double balloon enteroscope (Fujifilm, Tokyo, Japan) was used.We evaluated the success rate and time to reach the anastomosis or ampulla of Vater as a primary outcome. Other success rate (cannulation, completion of planned procedure) and incidence of adverse event was also analyzed as secondary outcome measure.

Results

The success rate for reaching was 91.4% (96/105) in PBCS and 90.5% (95/105) in BAE (odds ratio [95%CI]: 1.12, [0.44–2.89], p = .809). Mean required time to reach was 10.04 min. (SD, 9.62) in PBCS, 18.77 min. (SD, 13.21) in BAE and significantly shorter in PBCS (p < .001). The success rate to cannulate and complete the procedure was not significantly different (cannulation, 97.8% in the PBCS and 90.2% in the BAE, odds ratio [95%CI]: 4.88, [1.02–23.24], p = .062; completion, 88.6% in PBCS and 81.0% in BAE, odds ratio [95%CI]: 1.82, [0.84–3.95], p = .178), while the required time to cannulate and complete the procedure was significantly shorter in PBCS (cannulation, 2.7 min. (SD, 3.16) in PBCS, 7.13 min. (SD, 9.71) in BAE, p < .001; completion, 42.32 min. (SD, 25.15) in PBCS, 65.73 min. (SD, 31.23) in BAE, p < .001). The incidence of adverse event was significantly higher in BAE (20/105, 19.0%) than in PBCS (5/105, 4.8%) (p < .001).

Conclusion

PBCS-ERCP showed promising results for SAA cases with shorter procedure time and lower adverse event incidence compared to BAE-ERCP, despite no significant difference in success rates.

References

1. Mizukami T, Ogata H, Hibi T. "Passive-bending colonoscope" significantly improves cecal intubation in difficult cases. World J Gastroenterol 2012;18:4454-6.
2. Sato K, Shigiyama F, Ito S, et al. Colonoscopy using a small-caliber colonoscope with passive-bending after incomplete colonoscopy due to sharp angulation or pain. Surg Endosc 2013;27:4171-6.
3. Sato K, Ito S, Shigiyama F, et al. A prospective randomized study on the benefits of a new small-caliber colonoscope. Endoscopy 2012;44:746-53.
4. Nakaji S, Hirata N, Shiratori T, et al. Three successful cases of biliary tract disease with Roux-en-Y reconstruction treated by ERCP using PCF-PQ260L. JJBA 2014;28:89-94.(in Japanese)