Introduction

Hot snare polypectomy (HSP) has been commonly applied for 10-19 mm polyps. The incidence of delayed bleeding after HSP for 10-19 mm is reported to be 2.1-2.8% [1-2], which is not negligible and expected to be higher in cases with antithrombotic drug use. Blended or coagulation currents are commonly used for HSP, but the coagulation current causes thermal injury to the deeper submucosal layer including larger vessels, resulting in a risk for delayed bleeding [3]. Cold snare polypectomy (CSP) reduces the risk for delayed bleeding compared with HSP [4], but CSP for colorectal polyps 10-19 mm is unsatisfactory for its higher rates of incomplete resection, leading to a higher incidence of local recurrence [5]. We hypothesized that low-power pure cut current (LPPC) without coagulation current can decrease thermal injury and conducted a phase I study assessing the feasibility of LPPC HSP for 10-14 mm adenoma (UMIN Clinical Trials Registry; UMIN000037678). Although there was no delayed bleeding among 90 patients with 100 polyps, sample size was insufficient to assess the safety of LPPC HSP.

Aims & Methods

This study aimed to evaluate the safety of LPPC HSP for colorectal neoplasms. In this multicenter, retrospective, observational study, consecutive patients who underwent LPPC HSP for nonpedunculated colorectal neoplasms 10-14 mm at two Japanese institutions between December 2018 and March 2022 were evaluated. Data were collected from medical records and prospectively recorded databases of endoscopic and pathologic findings. LPPC HSP was performed using a 10-mm or 15-mm thin hexagonal snare with either of the following modes; PureCut, effect 1, 10W (ESG-300), Autocut, effect 1, 10 W (VIO300D), or Autocut, effect 0.4 (VIO3). We analyzed the treatment outcomes of LPPC HSP. We also compared the delayed bleeding rate of LPPC HSP with the historical control of HSP, which was set as 2.1% (55/2629) based on the previous meta-analysis [1], and calculated the power value using a one-sample proportion test.

Results

A total of 339 patients with 410 lesions sized 10-14 mm were identified. The en bloc and R0 resection rates were 94.9% and 86.7%, respectively. Immediate bleeding requiring hemostasis developed in 4 lesions (1.0%). No perforation developed. Delayed bleeding developed in two patients, both of them required hospital admissions but were conservatively managed without endoscopic hemostasis or blood transfusion. Delayed bleeding rate was 0.6% per patient (2/339). LPPC-HSP was associated with a 71.4% reduction in the risk of delayed bleeding compared to the historical control (2.1%), with a power of 80.4% using a 2-sided significance level of 0.1.

Table. Baseline characteristics and treatment outcomes of low-power pure cut hot snare polypectomy

Conclusion

Delayed bleeding rate of LPPC HSP for nonpedunculated colorectal neoplasms 10-14 mm was 0.6%, which may be lower than conventional HSP. A large prospective study is warranted to assess the safety of LPPC HSP.

References

1. Nishizawa T, Suzuki H, Goto O, et al. Effect of prophylactic clipping in colorectal endoscopic resection: A meta-analysis of randomized controlled studies. United European Gastroenterol J 2017;5:859-867.
2. Matsumoto M, Kato M, Oba K, et al. Multicenter randomized controlled study to assess the effect of prophylactic clipping on post-polypectomy delayed bleeding. Dig Endosc 2016;28:570-576
3. Takayanagi D, Nemoto D, Isohata N, et al. Histological Comparison of Cold versus Hot Snare Resections of the Colorectal Mucosa. Dis Colon Rectum 2018;61:964-970.
4. Chang LC, Chang CY, Chen CY, et al. Cold Versus Hot Snare Polypectomy for Small Colorectal Polyps: A Pragmatic Randomized Controlled Trial. Ann Intern Med 2023;176:311-319.
5. Djinbachian R, Iratni R, Durand M, et al. Rates of Incomplete Resection of 1- to 20-mm Colorectal Polyps: A Systematic Review and Meta-Analysis. Gastroenterology 2020;159:904-914.e12.

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).

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

Over the world, fecal occult blood testing (FOBT) is used as a colorectal cancer (CRC) screening method for middle age and older age, but there are problems such as sensitivity/specificity issues, low participation rates in primary and secondary screenings, and that the incidence/mortality rates of CRC are still high. Fusobacterium nucleatum (Fn) has been reported to be frequently detected in the feces of CRC patients in recent years, and it has been reported that screening sensitivity can be increased by combining it with Fn PCR testing. However, due to the cost and technical complexity of PCR, it has not yet been widely used in clinical practice. In this study, we developed a simple method using ELISA to measure antibodies against FadA expressed by Fn and evaluated its usefulness.

Aims & Methods

We evaluated FOBT, Fn PCR quantification, and Fn (ELISA) in 41 individuals diagnosed with CRC from April 2020 to December 2022 and 41 healthy volunteers without CRC. Subgroup analysis was also performed in CRC patients at each stage.

Results

The correlation coefficient between Fn PCR quantification and Fn (ELISA) was good at r=0.722, p<0.001. FOBT alone had a sensitivity of 61% and a specificity of 100%. In Fn ELISA, when cut off#1 was set to maximize the AUC in ROC, the sensitivity and specificity were 76% and 78%, respectively, and when combined with FOBT, the sensitivity was 90% and the specificity was 78%. In screening, high specificity is required, so we set cut off#2 Fn ELISA to achieve a specificity of 93% and performed analysis. When combined with FOBT, the sensitivity was 73% and the specificity was 93%. When targeting advanced cancer of stage II or higher, the sensitivity by combining FOBT and Fn ELISA was 100% at cut off#1 and 79% at cut off#2, while for early cancer, the sensitivity was 76% at cut off#1 and 59% at cut off#2, both of which were better than the sensitivity of FOBT alone.

Conclusion

By combining Fn measurement using ELISA with FOBT, it was possible to increase the diagnostic sensitivity and reduce false negatives compared to FOBT alone. There are challenges such as setting appropriate cut-off values for use in screening, but measuring Fn in addition to FOBT may improve screening accuracy and increase the participation rate in secondary screening, and in the future, we would like to evaluate its effectiveness even in populations with low prior probability of screening participation.

Introduction

Individuals with high-risk adenomas have increased risk of developing metachronous advanced adenomas and colorectal cancer after colonoscopy. While US and Japanese guidelines recommend triennial surveillance colonoscopy in this high-risk population, surveillance rate is suboptimal and barriers to surveillance colonoscopy should be investigated. Patient tolerance of bowel preparation (BP) affects the willingness to repeat colonoscopy. However, it is unknown whether poor tolerance of BP for index colonoscopy actually decreases the surveillance colonoscopy compliance.

Aims & Methods

This prospective study aimed to investigate the surveillance rate in patients with removal of high-risk adenomas and the predictors associated with the compliance in surveillance colonoscopy, focusing on the patient tolerance of BP for index colonoscopy. A prospective cohort study was conducted of 1157 consecutive outpatients receiving colonoscopy under moderate sedation between March and November 2019, and included patients aged 45-84 years old with removal of high-risk adenomas (≥ 1 cm, with villous features, with high-grade dysplasia, or ≥ 3 of any size). All patients with high-risk adenoma removal were educated to receive surveillance colonoscopy in 3 years, and surveillance rate was evaluated 3 years after removal of high-risk adenomas. Tolerance of BP was rated on a 5-point scale (1 = very intolerable to 5 = very tolerable) before receiving index colonoscopy and poor tolerance was defined as ≤ 2. The patients who did not receive surveillance colonoscopy were called to inquire the reasons. Patients who could not be contacted or had already died were excluded. Factors associated with surveillance colonoscopy compliance were determined by logistic regression analysis.

Results

A total 186 patients with high-risk adenomas were included, and 62 patients (33%) did not receive surveillance colonoscopy in 3 years. Poor tolerance of BP was found in 36 patients (36/186, 19%). The surveillance rate was significantly lower in patients with poor BP tolerance than those with good tolerance (48% vs 74%, P < 0.01), and decreased with poorer tolerance on index colonoscopy (P for trend < 0.05). In multivariate analysis, poor tolerance [odds ratio (OR)=2.45, 95% confidence interval (CI) 1.11-5.41] and absence of primary care physician (OR=4.63; 95% CI 1.60-13.4) were independent risk factors for non-compliance in surveillance colonoscopy. The main reason for non-compliance were unwillingness to repeat BP for surveillance colonoscopy (N =17/62, 27 %).

Conclusion

Our findings highlight the need for improvement of the surveillance colonoscopy rate, especially for patients who had poor tolerance to BP on index colonoscopy and absence of primary care physician. Providing a well-tolerated BP regimen may lead to an increase in surveillance colonoscopy compliance.

Introduction

The number of elderly people undergoing colonoscopy is increasing. Along with this trend, there has been an increase in the use of cold polypectomy as a safe procedure for elderly patients. However, it remains unclear whether cold polypectomy is effective for elderly patients.

Aims & Methods

We conducted a study to examine the prognosis of elderly patients who underwent Cold Polypectomy after 5 years.
We retrospectively studied elderly patients aged over 80 who underwent cold polypectomy at Sapporo Medical Center NTT EC between April 2014 and July 2016, and assessed their 5-year prognosis after the procedure (2019-2021).

Results

The number of Cold Polypectomy procedures performed in our hospital during the evaluation period for elderly patients aged 80 and above was 152 cases. The median age was 82 years (range: 80-89), and there were 34 cases (22.3%) of very elderly patients aged 85 years or older.
No cases of postoperative bleeding or complications were observed in any of the cases.
Upon confirmation of the condition after 5 years, 50.6% (77 cases) were unable to be followed up due to completion of outpatient visits, etc., 36.8% (56 cases) were confirmed to be alive, and 12.5% (19 cases) were confirmed to have passed away. Among the cases that resulted in death, 12 cases were due to cancer, 2 cases were due to pneumonia, 4 cases were due to cardiovascular-related deaths, and 1 case was due to liver cirrhosis. There were no deaths due to colorectal cancer among the cases that resulted in cancer-related deaths. And no cases of colorectal cancer treatment were observed after Cold Polypectomy. So there is a possibility of preventing the occurrence of new colorectal cancer, although it may not necessarily prevent colorectal cancer death.
We compared the Charlson Comorbidity Index (CCI) between the survival and death cases. The CCI was 1.65 in the survival cases and 3.31 in the death cases, showing a significantly higher value in the death cases (p<0.001). Additionally, we drew a ROC curve and obtained a cut-off value of 2 points.

Conclusion

Cold polypectomy can be a preventive measure for colorectal cancer even in elderly patients. Before deciding whether to perform a cold polypectomy on elderly patients, their individual suitability should be evaluated. CCI could potentially be used as a criterion for determining the suitability for the procedure.

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