Introduction

The organized, population-based National Colorectal Cancer (CRC) Screening Program in the Czech Republic is focused on asymptomatic individuals aged over 50. There are two methods available. Fecal occult blood test (FOBT) is offered by general practitioners annually at ages 50 – 54 and biennially at age ≥ 55 (followed by FOBT+ colonoscopy, if positive). And screening colonoscopy from age 50, repeated in 10 years interval, if negative. Both, FOBT+ colonoscopy and screening colonoscopy are considered preventive colonoscopies. FOBT performed in the laboratory is designated as diagnostic FOBT. Interval cancer is defined as a malignity diagnosed after an index exam (preventive, diagnostic, or therapeutic) in which no cancer is detected, and before the date of the next recommended exam.

Aims & Methods

The analysis included men and women of age ≥ 55 diagnosed with their first colorectal cancer in the period 2016-2020 (data source: National Cancer Registry). For those patients, the search of examinations in the National Registry of Reimbursed Health Services was performed focused on procedures in the period 0.5-5.5 years (depending on the type of examination; FOBT till 2.5 years, colonoscopy till 5.5 years) before the time of the cancer diagnosis: FOBT (screening and diagnostic), FOBT+colonoscopy and screening colonoscopy marked as preventive colonoscopy, diagnostic colonoscopy. As therapy, the endoscopic polypectomy, mucosal resection, and submucosal dissection performed within 6 months of the mentioned examinations were considered.

Results

There were colorectal cancers in 30,723 patients found (Table 1), with 13,816 cancers in stages III and IV (45.0%). The majority of the patients (64.4%) did not undergo any observed procedure. 20.3% of patients had negative FOBT, so, they were considered as patients with interval cancer. Preventive colonoscopies were accompanied by a low rate of interval cancers (0.9%).

Procedures in patients with colorectal cancer	All stages No. (%)	Advanced stages (II and IV) No. (%)
Preventive colonoscopy with therapy	354 (1.2%)	126 (0.9%)
Preventive colonoscopy without therapy	289 (0.9%)	123 (0.9%)
Screening FOBT positive with diagnostic colonoscopy	279 (0.9%)	72 (0.5%)
Screening FOBT positive without any diagnostic colonoscopy	1,073 (3.5%)	447 (3.2%)
Screening FOBT negative	6,228 (20.3%)	2,769 (20.0%)
Diagnostic colonoscopy	2197 (7.2%)	879 (6.4%)
Diagnostic FOBT	509 (1.7%)	223 (1.6%)
No examination	19,794 (64.4%)	9,177 (66.4%)
Total	30,723	13,816

Conclusion

The highest number of colorectal cancers was found in patients with no procedures related to CRC incidence and mortality reduction (preventive, diagnostic, or therapeutic). Approximately 20% of people with colorectal cancers had interval carcinoma (after negative screening FOBT) which could be caused by the inappropriate setting of FOBT examination or low sensitivity of FOBT. The higher proportion of cancers after negative screening FOBT might be also caused by the fold higher number of procedures FOBT performed.

References

Supported by the Czech Ministry of Health grants NV18-08-00246 and NU22-08-00424 and projects MO1012 and Cooperatio.

Introduction

Sessile Serrated Lesions (SSLs) show an “ultra flat” morphology, a mucus cap and are predominantly located proximally to the splenic flexure (PSF) (1). Hypothetically, previous knowledge in detection of flat or non-protruding conventional adenoma could be a predictor factor for endoscopic detection of SSLs.

Aims & Methods

Aim: To investigate in a South American Private Hospital, the relationship between Flat Adenomas Detection Rate (FADR) and Sessile Serrate Lesion Detection Rate (SDR)
Methods: This study is a retrospective, single-center analysis carried out at Centro Medico Docente La Trinidad Caracas-Venezuela from total selected colonoscopies performed by the gastroenterologists between 2008 and 2018 in patients 51-80 years old (YO). For this study, Adenoma Detection Rate (ADR) includes the whole morphologic spectrum of colon & rectum traditional adenomas from Paris Classification of Colorectal Lesions (2). We will consider the “General ADR” as “GADR”, including Non-protruding or flat ADR: “FADR” plus Protruding ADR: “PADR”, as well as the last two separately. By using logistic regression generalized estimating equation models, the location in colon & rectum and morphology of all types of adenomas (ADs) were assessed. The relationship between the global number of colonoscopies (GNC), GADR, FADR, PADR and the SDR was investigated calculating a correlation coefficient (CC) weighted by the number of total colonoscopies. In addition, 3 linear regression equation models to estimate the relationship between the 3 different types of ADR and SDR and the probability of occurrence of SDR based on the proportion of colonoscopies with SDR presenting every type of ADR weighted by the number of colonoscopies with SDR were calculated.

Results

Results of the linear regression models used to estimate the relationship between the different types of ADR and SDR and the probability of occurrence based on the number of Centro Medico Docente La Trinidad colonoscopies
Category of ADR	R2	β	P	SDR Correlation coefficient	Probability of occurrence (%)	Colonoscopies in each category of ADR validated for SDR calculation
General ADR	0.9687	0.1632	<0.001	0.9842	94.26	148
Flat ADR	0.759	1.888	0.002	0.8712	92.35	145
Protruding ADR	0.3186	0.1664	0.113	0.5644	37.58	59
R2 : Determination coefficient. This evaluates the strength of the linear relationship between the two variables.
β: Partial regression coefficient. It indicates the average effect that the increase in one unit of the predictor variable has on the dependent variable.
ADR: Adenoma Detection Rate. SDR: Serrated Detection Rate. 157 colonoscopies were valid for the calculation of the SDR

For this study, 8432 colonoscopies were validated for 9 gastroenterologists (G1-G9). For patients between 51 and 80 YO, GADR for all 9 Gastroenterologists was 19.76%. GADR-SDR individually for 9 gastroenterologists (G1-G9) varies from as high as G9 GADR-SDR: 33.21%-4.19% to as low as G1: 12.67%-0.50%. The most frequent location for ADs was PSF: OR 1.95, IC 95% (1.30-2.84), P<0.001. SSLs were mostly located PSF OR 2.18, IC 95% (1.44, 2.92) P<0.001. The morphology of ADs was mainly pedicle OR 1.00 IC 95% P<0.001 and for SSL it was flat by far: OR 6.84 IC 95% (2.08-9.02) P<0.001. The CC demonstrated a good association between GADR and SDR: 0.98 P<0.05; and for FADR: 0.87, P<0.05 but not for PADR: 0.56 P=0.113. The GNC was not associated with the SDR CC: -0.197, P=0.6117. The GADR and FADR show robust strength of the linear relationship with SDR and probability of occurrence, but not for PADR (table)

Conclusion

A sine qua non factor for a good SDR for the gastroenterologist is previous knowledge about “FADR”. To the best of our knowledge, this is the first time that ADR has been divided into “General, Flat and Protruded” in order to investigate the impact of the endoscopic skills on flat colorectal lesions detection for a good SDR.

References

1. Rex DK, Ahnen DJ, Baron JA et al. Serrated lesions of the colorectum: review and recommendations from an expert panel. Am J Gastroenterol 2012; 107: 1315-1329; quiz 1314, 1330 [PMID: 22710576 DOI: 10.1038/ ajg.2012.161]
2. Lambert R et al. Superficial Neoplastic Lesions in the Digestive Tract. Endoscopy 2005; 37: 570±578

Introduction

Cold snare polypectomy (CSP) for polyps 10-14 mm is unsatisfactory, with higher rates of unclear/positive histologic margins compared to small polyps,¹ which is similar for CSP with submucosal injection.² Therefore, hot snare polypectomy (HSP) or endoscopic mucosal resection (EMR) has been widely performed for polyps measuring ≥10 mm.³ However, these procedures often cause adverse events such as delayed bleeding and perforation due to deep thermal injury related to the use of electrocautery.⁴ A recent large-scale study reported a low incidence (0.9%) of invasive cancer in 10-19 mm colorectal polyps.⁵ Therefore, the development of less invasive therapeutic options for this size category is demanding.
Thus, we have developed HSP with low power pure-cut current (LPPC-HSP), a polypectomy technique with low power, low voltage, and no coagulation current (UMIN Clinical Trials Registry; UMIN000037678). This method uses pure-cut current and reduces the power of electrocautery, expecting less deep thermal damage compared with conventional HSP with blend or coagulation current, resulting in a lower risk of perforation and bleeding. This study aimed to evaluate the efficacy and safety of LPPC-HSP for colorectal polyps 10 to 14 mm, compared with conventional EMR.

Aims & Methods

In this multicenter, retrospective, observational study, records of patients who underwent EMR or LPPC-HSP for nonpedunculated colorectal polyps 10 to 14 mm at two Japanese institutions between January 2021 and March 2022 were evaluated consecutively. EMR was performed with blend cut current (Endocut Q; effect 3, time interval 2, time duration 2), while LPPC-HSP with a low power pure-cut current (Autocut; effect 1, 10 W in VIO300D or Autocut; effect 0.4 [Pmax 13 W] in VIO3). We analyzed the treatment outcomes of the two techniques using propensity score matching to reduce selection bias. The following variables expected to affect treatment outcomes were selected: age, sex, polyp size, morphology, lesion location, endoscopists (experienced endoscopists or gastrointestinal fellows), and antithrombotic agents. R0 resection was defined as en bloc resection with histologically tumor-free margins.

Results

We retrospectively enrolled 203 EMR (168 patients, 203 lesions) and 208 LPPC-HSP (169 patients, 208 lesions) cases. After propensity score matching, the baseline characteristics between the groups were comparable, with 131 pairs. The en bloc and R0 resection rates were not significantly different between EMR and LPPC-HSP groups (93.9% vs. 96.9%, P=0.38; 90.8% vs. 91.6%, P=1.00). The vertical margin was negative in all lesions except one in the EMR group. Immediate bleeding requiring hemostasis was observed in 10.7% of cases in the EMR group versus 2.3% in the LPPC-HSP group (P=0.010). The rates of delayed bleeding and perforation didn’t differ between the groups (0% vs. 0.8%, P=1.00; 0% vs. 0%).

Table 1. Baseline characteristics and treatment outcomes after propensity score matching
Baseline characteristics	EMR n=131	LPPC-HSP n=131	P value	standardized difference		Treatment outcomes	EMR n=131	LPPC-HSP n=131	P value
Age, years (interquartile range)	72 (67-76)	72 (68-78)	0.29	0.105		En bloc resection (%)	123 (93.9)	127 (96.9)	0.38
Male sex (%)	91 (70)	96 (73)	0.59	0.085		R0 resection (%)	119 (90.8)	120 (91.6)	1.00
Lesion size, mm (interquartile range)	10 (10-12)	10 (10-12)	0.93	0.017		Immediate bleeding (%)	14 (10.7)	3 (2.3)	0.01
Location right colon/left colon/rectum (%)	61 (47) / 53 (41) / 17 (13)	63 (48) / 53 (41) / 15 (12)	0.95	0.049		Delayed bleeding (%)	0 (0)	1 (0.8)	1.00
Morphology 0-Is/0-IIa (%)	89 (68) / 42 (32)	87 (66) / 44 (34)	0.90	0.033		Perforation (%)	0 (0)	0 (0)	N/A
Antithrombotic agents (%)	24 (18)	35 (27)	0.14	0.202
Gastrointestinal fellows performed (%)	42 (32)	44 (34)	0.90	0.033

Conclusion

LPPC-HSP showed treatment outcomes comparable to conventional EMR, with fewer adverse events. These results suggest that this technique is a safe and effective treatment for nonpedunculated colorectal polyps 10 to 14 mm.

References

1. Hirose R, Yoshida N, Murakami T, et al. Histopathological analysis of cold snare polypectomy and its indication for colorectal polyps 10-14 mm in diameter. Dig Endosc 2017;29:594-601.
2. Yabuuchi Y, Imai K, Hotta K, et al. Efficacy and safety of cold-snare endoscopic mucosal resection for colorectal adenomas 10 to 14 mm in size: a prospective observational study. Gastrointest Endosc 2020;92:1239-1246.
3. Ferlitsch M, Moss A, Hassan C, et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017;49:270-297.
4. Oka S, Tanaka S, Kanao H, et al. Current status in the occurrence of postoperative bleeding, perforation and residual/local recurrence during colonoscopic treatment in Japan. Dig Endosc 2010;22:376-380.
5. Parsa N, Ponugoti P, Broadley H, et al. Risk of cancer in 10 - 19 mm endoscopically detected colorectal lesions. Endoscopy 2019;51:452-457.

Disclosure

Authors declare no Conflict of Interests for this study.

Introduction

Colorectal adenomatous polyp is a precancerous lesion. Screening for detection and removal of colorectal adenomatous polyps has been shown to reduce mortality related to colorectal cancer. Recent studies have shown that colorectal adenomatous polyp is associated with atherosclerosis. Cardio-ankle vascular index (CAVI) and ankle-brachial index (ABI) are non-invasive methods to evaluate atherosclerosis and cardiovascular disease as well as peripheral artery disease. This study aimed to investigate the association between atherosclerosis and high-risk adenoma based on CAVI and ABI.

Aims & Methods

We retrospectively analyzed data of patients aged ≥ 50 years who had CAVI, ABI, and a colonoscopy from August 2015 to December 2021 in Kangwon National University Hospital. After having a colonoscopy, subjects were divided into groups with and without adenoma or high-risk adenoma (size ≥ 1 cm, high-grade dysplasia or villous adenoma, 3 or more adenomas) based on pathologic findings. Data were then subjected to univariate and multivariate logistic regression analyses.

Results

A total of 1,164 subjects were included. Adenomas were found in 613 (52.6%) subjects and the high-risk adenomas were found in 118 (10.1%) subjects. The rate of positive ABI (< 0.9) and positive CAVI (≥ 9.0) were significantly higher in the high-risk adenoma group (22.0% and 55.9%) than those in the no adenoma (12.3% and 39.6%) and the overall adenoma group (15.7% and 44.0%) (p = 0.008 and p = 0.006, respectively). In a multivariate analysis, positive CAVI and smoking were significantly associated with high-risk adenoma (p = 0.027 and p = 0.021, respectively).

Conclusion

In this study, a significant correlation between positive CAVI and high-risk adenoma was observed. The use of CAVI could be a significant predictor of the presence of a high-risk adenoma.

References

1. Daniel Trabulo, Suzane Ribeiro, Cláudio Martins et al. Metabolic syndrome and colorectal neoplasms: An ominous ssociation. World J Gastroenterol 2015 May 7; 21(17): 5320-5327
2. JungHyun Lee, Kun Sei Lee, Hyeongsu Kim et al. The relationship between metabolic syndrome and the incidence of colorectal cancer. Environmental Health and Preventive Medicine (2020) 25:6
3. K. Yamamoto, T. Miyata and H. Nagawa. The High Prevalence of Colorectal Neoplasms in Preoperative Patients with Abdominal Aortic Aneurysm or Peripheral Artery Disease. Eur J Vasc Endovasc Surg 33, 397e400 (2007)
4. Pilar Ángeles Oriol Toróna, Teresa Badía Farréa, Amparo Romaguera Lliso et al. Metabolic syndrome and peripheral artery disease: Two related conditions. Endocrinol Nutr. 2016;63(6):258-264
5. Hung-Yu Chen, Wen-Huang Lee, Ting-Hsing Chao et al. Arterial stiffness is associated with high-risk colorectal adenomas and serrated lesions: A cross-sectional study in a Taiwanese population. Journal of Cardiology 2022;80: 139–144
6. Gi-hyang Lee, Su-bin Kang ,Sei-young Kang et al. The relationship between Cardio-Ankle Vascular Index(CAVI), Ankle-Brachial Index(ABI), and factors related to arteriosclerosis. J.Int.Korean Med. 2020;41(3):434-446
7. Jin Lee, Joo Wan Seo, Tae Oh Kim et al. Predictors of High-Risk Adenoma Occurrence at Surveillance Colonoscopy in Patients Who Undergo Colorectal Adenoma Removal. Digestive Diseases 2018;36:354–361

Introduction

Since currently utilized screening tools including fecal immunochemical test and serum tumor markers cannot reveal sufficient diagnostic powers for colorectal cancer (CRC) due to their low sensitivities. It is thus hopeful to discover non-invasive diagnostic biomarkers for CRC. Urine is one of the most attractive samples for mass-screening because of the non-invasiveness and easy handling. We have previously reported many types of urinary biomarkers for gastrointestinal malignancies.

Aims & Methods

We conducted the current study to discover and establish urinary protein biomarkers that enables early detection of CRC. Among 475 patients including 299 healthy controls (HCs) and 175 stage 0-III CRC patients, age- and sex-matched 373 patients were enrolled in this case-control study. A whole cohort was randomly divided into the discovery cohort (n=32), training cohort (n=220) and validation cohort (n=111). In the discovery cohort, we have performed the isobaric tags for relative and absolute quantitation (iTRAQ) -coupled liquid chromatography-mass spectrometry (LC-MS) to identify urinary protein biomarker candidates. After that, the urinary protein biomarkers were established with ELISA in the training cohort. Finally, the established biomarkers were validated with ELISA in the independent validation cohort.

Results

In the discovery cohort, we identified 78 urinary proteins with aberrant expression between HCs and CRC patients. Among them, urinary levels of 11 proteins were significantly higher in the CRC patients than in the HCs, and 4 urinary proteins were independent biomarkers on the multivariate analysis in the training cohort. In the validation cohort, these urinary proteins also showed significantly higher levels in the CRC patients than in the HCs. Of these urinary biomarkers, DPEP1 and TFF1 were top two urinary protein biomarkers for the diagnosis of CRC, and the combination biomarker panel using these two proteins showed an excellent AUC of 0.870 with 94.3% sensitivity and 63.4% specificity for the diagnosis of stage 0-III CRC. Notably, this combination biomarker panel could distinguish stage 0-I CRC that are curable with endoscopic resection, with an AUC of 0.852, 93.8% sensitivity and 61.6% specificity.

Conclusion

The established novel urinary biomarker panel provides a promising method for early detection of CRC with completely non-invasive manner.

Introduction

Liver steatosis represents the hepatic manifestation of increased adiposopathy, whose pathogenetic features have been proposed as tumorigenic triggers, specifically in colorectal cancer (CRC) [1]. Fatty liver diagnosis challenges clinicians since it is clinically silent and may be complicated with liver fibrosis. Since liver biopsy is not feasible in all patients, non-invasive and point-of-care indexes have been proposed to detect liver steatosis and fibrosis [2].

Aims & Methods

We performed a retrospective analysis among 1145 metabolic subjects to reveal any condition that may predict and concur to CRC development during a 8-years period. Anthropometric and bio humoral parameters were recorded at time zero. Non-invasive liver fibrosis scores were calculated as follows: AAR=AST/ALT; FIB-4=(age x AST)/(platelet count x √ALT); mFIB-4=(10 x age x AST)/(platelet count x ALT); Forns=7.811 - 3.131 x  ln(platelet count)  + 0.781 x ln(GGT)  + 3.467 x ln(age) - 0.014  x (total cholesterol); APRI= AST/Upper limit of normal values x 100/platelet count; AARPRI=AST/ALT/platelet count x 150. Comparisons were carried out by Student-T test (p-value <0.05 was considered significant) and ROC analysis was performed to assess cut-off values. Chi-square test was used to calculate the associated Odds Ratio (OR) with 95% confidence interval (CI).

Results

During a 8 years period, 28 patients (2.4%) developed CRC. No association between CRC development and visceral and general obesity was detected, while fasting plasma glucose was significantly higher and Vitamin D was significantly lower in patients who later were diagnosed with CRC, compared to those who did not develop cancer. We found that all non-invasive liver fibrosis scores significantly identified CRC-developer at time 0 (see Table). In ROC analysis, these scores also showed good sensitivity and specificity in predicting colon cancer (AAR AUC= 0.59, sensitivity 44% and specificity 78%; FIB-4 AUC= 0.74, sensitivity 84% and specificity 57%; mFIB-4 AUC=0.69, sensitivity 80% and specificity 53%; Forns AUC= 0.67, sensitivity 73% and specificity 54%; APRI AUC= 0.63, sensitivity 57% and specificity 75%; AARPRI AUC =0.64, sensitivity 44% and specificity 83%). We then calculated ORs for values above the ROC cut-offs finding that higher FIB-4 was associated with a 6-fold increased risk of developing CRC (95% CI=2.2-16.5), while mFIB-4 showed a OR=3.6 (95% CI=1.4-8.7), Forns OR was 3.1 (95% CI=1.3-7.9), APRI OR was 3.2 (95% CI=1.4-6.9) and AARPRI OR was 3 (95% CI=1.3-6.4).

	No Cancer (n=1117) mean ± SD	Colon cancer (n=28) mean ± SD	p-value
Fasting glucose (mg/dL)	100.8±29.1	119.5±49.8	0.0011
25-OH Vitamin D (pg/mL)	22.8±11.2	16.3±7.8	0.0099
AAR	0.8±0.3	1±0.5	0.0064
FIB-4	1.1±0.7	1.8±1	<0.0001
mFIB-4	2.2±1.5	3.3±2.3	0.0004
Forns	5.3±1.8	6.3±1.3	0.0039
APRI	0.3±0.2	0.5±0.4	0.0003
AARPRI	0.6±0.3	0.8±0.5	0.0011

Conclusion

These findings support the hypothesis that liver steatosis and fibrosis may play a role in the clinical background of CRC and bring to light the fascinating possibility of a reversed gut-liver axis communication in the pathogenesis of CRC. Thus, the use of non-invasive scores of liver fibrosis may be helpful to predict the risk of CRC and serve as novel prognostic factors for prevention and therapeutic strategies.

References

[1] Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med 2003;348:1625–38. https://doi.org/10.1056/NEJMoa021423.
[2] Hernandez Roman J, Siddiqui MS. The role of noninvasive biomarkers in diagnosis and risk stratification in nonalcoholic fatty liver disease. Endocrinol Diabetes Metab 2020;3:e00127. https://doi.org/10.1002/edm2.127.

Introduction

Disorders of Gut-Brain Interaction (DGBI) are common, affecting 40% of the global population¹. They are associated with psychological distress and somatisation, and detrimentally impact quality of life. The prevalence of DGBI is highest amongst young adults, with medical students reportedly having higher rates than the general population. However, data assessing the prevalence and burden of DGBI amongst medical students is mainly confined to studies from Asia and Africa.

Aims & Methods

We aimed to assess the prevalence and burden of DGBI amongst medical students within a UK based university. An internet-based, cross-sectional, anonymous health survey on physical and mental health was disseminated to medical students enrolled at the University of Sheffield (UK). Information on demographics, past medical history, and gastrointestinal symptoms were collected, the latter using the Rome IV diagnostic questionnaire to determine the presence of DGBI. Additional validated questionnaires screened for somatisation, psychological distress, eating disorders, quality of life, and burnout.

Results

The questionnaire was completed by 378 of 1621 medical students (mean age 21 years, 73% female, and 70% white). The prevalence of having at least one DGBI was 76% (n=289), of which two-of-three had multiple affected sites. The most frequently met diagnostic criteria for DGBI were gastroduodenal (57%), followed by bowel (49%), oesophageal (29%), and anorectal (26%) disorders. Approximately 50% of students with DGBI experienced painful gastrointestinal symptoms at least one day per week.
Compared to students without DGBI, those with DGBI had significantly higher anxiety and depression scores, increased somatic symptom reporting, reduced mental and physical quality of life, poorer eating habits, and more frequent medication use (p-values, all <0.05). They were also at significantly higher risk of burnout, including study exhaustion and disengagement. The greatest health impairment across these domains was seen in those with multiple, painful, DGBI. Only 23% and 5% of students with DGBI had consulted a primary care provider and gastroenterologist, respectively, for their gastrointestinal symptoms.

Conclusion

DGBI are common amongst UK medical students and are associated with psychological distress, somatisation, reduced quality of life, and burnout. However, students with DGBI infrequently seek help for gastrointestinal symptoms. Greater awareness of the high prevalence and burden of DGBI amongst medical students may lead to increased support, improvement in health status, and better study engagement.

References

1. Sperber AD et al. Worldwide Prevalence and Burden of Functional Gastrointestinal Disorders, Results of Rome Foundation Global Study. Gastroenterology. 2021 Jan;160(1):99-114