Incidence, Mechanisms of Injury and Mortality of Severe Traumatic Brain Injury: An Observational Population-Based Cohort Study from New Zealand and Norway.

BACKGROUND: Comparing trauma registry data from different countries can help to identify possible differences in epidemiology, which may help to improve the care of trauma patients. METHODS: This study directly compares the incidence, mechanisms of injuries and mortality of severe TBI based on population-based data from the two national trauma registries from New Zealand and Norway. All patients prospectively registered with severe TBI in either of the national registries for the 4-year study period were included. Patient and injury variables were described and age-adjusted incidence and mortality rates were calculated. RESULTS: A total of 1378 trauma patients were identified of whom 751 (54.5%) from New Zealand and 627 (45.5%) from Norway. The patient cohort from New Zealand was significantly younger (median 32 versus 53 years; p < 0.001) and more patients from New Zealand were injured in road traffic crashes (37% versus 13%; p < 0.001). The age-adjusted incidence rate of severe TBI was 3.8 per 100,000 in New Zealand and 2.9 per 100,000 in Norway. The age-adjusted mortality rates were 1.5 per 100,000 in New Zealand and 1.2 per 100,000 in Norway. The fatality rates were 38.5% in New Zealand and 34.2% in Norway (p = 0.112). CONCLUSIONS: Road traffic crashes in younger patients were more common in New Zealand whereas falls in elderly patients were the main cause for severe TBI in Norway. The age-adjusted incidence and mortality rates of severe TBI among trauma patients are similar in New Zealand and Norway. The fatality rates of severe TBI are still considerable with more than one third of patients dying.

Structured and Systematic Team and Procedure Training in Severe Trauma: Going from 'Zero to Hero' for a Time-Critical, Low-Volume Emergency Procedure Over Three Time Periods.

BACKGROUND: Resuscitative emergency thoracotomy is a potential life-saving procedure but is rarely performed outside of busy trauma centers. Yet the intervention cannot be deferred nor centralized for critically injured patients presenting in extremis. Low-volume experience may be mitigated by structured training. The aim of this study was to describe concurrent development of training and simulation in a trauma system and associated effect on one time-critical emergency procedure on patient outcome. METHODS: An observational cohort study split into 3 arbitrary time-phases of trauma system development referred to as 'early', 'developing' and 'mature' time-periods. Core characteristics of the system is described for each phase and concurrent outcomes for all consecutive emergency thoracotomies described with focus on patient characteristics and outcome analyzed for trends in time. RESULTS: Over the study period, a total of 36 emergency thoracotomies were performed, of which 5 survived (13.9%). The "early" phase had no survivors (0/10), with 2 of 13 (15%) and 3 of 13 (23%) surviving in the development and mature phase, respectively. A decline in 'elderly' (>55 years) patients who had emergency thoracotomy occurred with each time period (from 50%, 31% to 7.7%, respectively). The gender distribution and the injury severity scores on admission remained unchanged, while the rate of patients with signs on life (SOL) increased over time. CONCLUSION: The improvement over time in survival for one time-critical emergency procedure may be attributed to structured implementation of team and procedure training. The findings may be transferred to other low-volume regions for improved trauma care.

Incidence and characteristics of pancreatic injuries among trauma patients admitted to a Norwegian trauma centre: a population-based cohort study.

BACKGROUND: Pancreatic injuries are rare. Reports are lacking from defined European populations covering all ages and genders and in areas with a low prevalence of penetrating trauma. We aimed to review pancreatic injuries identified within a defined population. METHODS: Observational cohort study from a prospectively maintained trauma registry and all patients coded for a pancreatic injury between January 1, 2004 and December 31, 2018. RESULTS: A total of 14 patients with pancreatic injury were identified over a 15-year time period. Pancreatic injuries represented 0,19% (14/7207) of all trauma patients and 3,1% (14/454) of patients with documented abdominal injuries. Nine patients 64% (9/14) were children, representing 1% (9/869) of all injured children in the registry and 11,4% (9/79) of children with documented abdominal injuries. Median age was 10,5 years (range 3-58). Ten were male (71%) and 86% (12/14) suffered blunt trauma. Median AAST-OIS was 2 (1-4). Single organ injury occurred in 43% (6/14). Concomitant liver injury was the most frequent associated intra-abdominal injury found in 29% (4/14). Four patients (29%) had associated injuries in other body regions, all thoracic injuries. Median ISS was 9,5 (4-41).Operative management was needed for four of the pancreatic injuries, one spleen-preserving distal pancreatectomy, one spleen-sacrificing distal pancreatectomy and two peripancreatic drainages. One patient died within 30-days, but the death was unrelated to the pancreatic injury. CONCLUSIONS: Incidence of pancreatic injuries is low, even among trauma patients with documented abdominal injuries. Most pancreatic injuries occurred in children. Injuries requiring surgery was rare.

Perforated peptic ulcer.

Perforated peptic ulcer is a common emergency condition worldwide, with associated mortality rates of up to 30%. A scarcity of high-quality studies about the condition limits the knowledge base for clinical decision making, but a few published randomised trials are available. Although Helicobacter pylori and use of non-steroidal anti-inflammatory drugs are common causes, demographic differences in age, sex, perforation location, and underlying causes exist between countries, and mortality rates also vary. Clinical prediction rules are used, but accuracy varies with study population. Early surgery, either by laparoscopic or open repair, and proper sepsis management are essential for good outcome. Selected patients can be managed non-operatively or with novel endoscopic approaches, but validation of such methods in trials is needed. Quality of care, sepsis care bundles, and postoperative monitoring need further assessment. Adequate trials with low risk of bias are urgently needed to provide better evidence. We summarise the evidence for perforated peptic ulcer management and identify directions for future clinical research.

Characteristics and demography of low energy fall injuries in patients > 60 years of age: a population-based analysis over a decade with focus on undertriage.

BACKGROUND: An increasing group of elderly patients is admitted after low energy falls. Several studies have shown that this patient group tends to be severely injured and is often undertriaged. METHODS: Patients > 60 years with low energy fall (< 1 m) as mechanism of injury were identified from the Stavanger University Hospital trauma registry. The study period was between 01.01.11 and 31.12.20. Patient and injury variables as well as clinical outcome were described. Undertriage was defined as patients with a major trauma, i.e., Injury Severity Score (ISS) > 15, without trauma team activation. Statistical analysis was performed using the Chi-squared test for categorical variables and the Mann-Whitney U test for continuous variables. RESULTS: Over the 10-year study period, 388 patients > 60 years with low energy fall as mechanism of injury were identified. Median age was 78 years (IQR 68-86), and 53% were males. The location of major injury was head injury in 41% of the patients, lower extremities in 19%, and thoracic injuries in 10%. Thirty-day mortality was 13%. Fifty percent were discharged to home, 31% to nursing home, 9% in hospital mortality, and the remaining 10% were transferred to other hospitals or rehabilitation facilities. Ninety patients had major trauma, and the undertriage was 48% (95% confidence interval, 38 to 58%). CONCLUSIONS: Patients aged > 60 years with low energy falls are dominated by head injuries, and the 30-day mortality is 13%. Patients with major trauma are undertriaged in half the cases mandating increased awareness of this patient group.

Health Care Implications of the COVID-19 Pandemic for Patients with Severe Traumatic Brain Injury-A Nationwide, Observational Cohort Study.

BACKGROUND: Containment measures during the coronavirus disease of 2019 (COVID-19) pandemic have resulted in a substantial reduction in treatment of injury. The effect of the COVID-19 pandemic on the epidemiology and mortality of severe traumatic brain injury on a national, population-based level is unknown. METHODS: Data on all patients with severe traumatic brain injury between 2017 and 2020 were retrieved from the National Trauma Registry of Norway. The study cohort was derived from the pandemic period (March 12 to December 31, 2020) and the control cohort from the prepandemic years 2017 to 2019. The outcome measures were 30-day mortality, in-hospital mortality, and discharge destination. RESULTS: This study included 522 trauma patients with severe traumatic brain injury, 387 (74.1%) in the prepandemic and 135 (25.9%) in the pandemic period. Length of stay increased significantly during the pandemic period (4 vs. 3 days; P = 0.014). The 30-day mortality rate was 39% (n = 149) in the prepandemic versus 38% (n = 52) pandemic period (P = 0.998). In-hospital mortality was 33% (n = 128) in the prepandemic versus 33% (n = 44) in the pandemic period (P = 0.920). There were no statistically significant differences in discharge destination besides the number of patients discharged to home in the pandemic period (P = 0.003). When adjusted for clinical relevant factors such as age, gender, and head injury severity, the mortality outcomes did not change during the pandemic period. CONCLUSIONS: The containment and lockdown measures during the COVID-19 pandemic in Norway did not affect the number of patients or mortality of patients with severe traumatic brain injury.

Characteristics, image findings and clinical outcome of moderate and severe traumatic brain injury among severely injured children: a population-based cohort study.

PURPOSE: The aim of this study was to explore patient and injury characteristics, image findings, short-term clinical outcome and time trends of moderate and severe traumatic brain injury in severely injured children. METHODS: This study is an observational cohort study based on prospectively collected data from an institutional trauma registry database covering all trauma patients in South West Norway. All paediatric patients registered in the database between 01.01.2004 and 31.12.2019 were included. RESULTS: During the 16 years-study periods, 82 paediatric patients with moderate (n = 42) and severe (n = 40) traumatic brain injury were identified. Median age was 13.0 years, 45% were female and median Glasgow Coma Scale score at admission was 9.0. Cranial fractures were common image findings in both groups. Cerebral contusions (32%) and epidural hematomas (29%) were more commonly found in moderate traumatic brain injury; cerebral contusions (49%), diffuse axonal injury (31%) and cerebral oedema (46%) were more prominent in severe traumatic brain injury. All children with moderate traumatic brain injury survived and favourable outcome was registered in 98%. Overall mortality in the severe traumatic brain injury cohort was 38% (thereof 25% due to TBI) and only 38% had a favourable short-term outcome. CONCLUSIONS: In this population-based study on paediatric trauma patients over a period of 16 years severe traumatic brain injury in children still had a considerably high mortality and a higher proportion of patients experienced an unfavourable clinical short-term outcome. Moderate traumatic brain injury resulted in favourable clinical outcome.

Is there a weekend effect on mortality rate and outcome for moderate and severe traumatic brain injury? A population-based, observational cohort study.

Purpose: The aim of the study was to analyse patient and injury characteristics and the effects of weekend admissions on mortality rate and outcome after moderate and severe traumatic brain injuries. Methods: This is an observational cohort study based on data from a prospectively maintained regional trauma registry in South Western Norway. Patients with moderate and severe traumatic brain injury admitted between January 1st, 2004 and December 31st, 2019 were included in this study. Results: During the study period 688 patients were included in the study with similar distribution between moderate (n â€‹= â€‹318) and severe (n â€‹= â€‹370) traumatic brain injury. Mortality rate was 46% in severe and 13% in moderate traumatic brain injury. Two hundred and thirty-one (34%) patients were admitted during weekends. Patients admitted during weekends were significantly younger (median age (IQR) 32.0 (25.5-67.0) vs 47.0 (20.0-55.0), p â€‹< â€‹0.001). Pre-injury ASA 1 was significantly more common in patients admitted during weekends (n â€‹= â€‹146, 64%, p â€‹= â€‹0.001) while ASA 3 showed significance during weekdays compared to weekends (n â€‹= â€‹101, 22%, p â€‹= â€‹0.013). On binominal logistic regression analysis mortality rate was significantly higher with older age (OR 1.03, 95% CI for OR 1.02-1.04, p â€‹< â€‹0.001) and increasing TBI severity (OR 7.08, 95% CI for OR 4.67-10.73, p â€‹< â€‹0.001). Conclusions: Mortality rate and poor clinical outcome remain high in severe traumatic brain injury. While a higher number of patients are admitted during the weekend, mortality rate does not differ from weekday admissions.

Epidemiology of abdominal trauma: An age- and sex-adjusted incidence analysis with mortality patterns.

PURPOSE: Abdominal injuries may occur in up to one-third of all patients who suffer severe trauma, but little is known about epidemiological trends and characteristics in a Northern European setting. This study investigated injury demographics, and epidemiological trends in trauma patients admitted with abdominal injuries. METHODS: This was an observational cohort study of all consecutive patients admitted to Stavanger University Hospital (SUH) with a documented abdominal injury between January 2004 and December 2018. Injury demographics, age- and sex-adjusted incidence, and mortality patterns are analyzed across three time periods. RESULTS: Among 7202 admitted trauma patients, 449 (6.2%) suffered abdominal injuries. The median age was 31 years, and the age increased significantly over time (from a median of 25 years to a median of 38.5 years; p = 0.020). Patients with ASA 2 and 3 increased significantly over time. Men accounted for 70% (316/449). The injury mechanism was blunt in 91% (409/449). Transport-related accidents were the most frequent cause of injury in 57% (257/449). The median Injury Severity Score (ISS) was 21, and the median New Injury Severity Score (NISS) was 25. The annual adjusted incidence of all abdominal injuries was 7.2 per 100,000. Solid-organ injuries showed an annual adjusted incidence of 5.7 per 100,000. The most frequent organ injury was liver injury, found in 38% (169/449). Multiple abdominal injuries were recorded in 44% (197/449) and polytrauma in 51% (231/449) of the patients. Overall 30-day mortality was 12.5% (56/449) and 90-day mortality 13.6% (61/449). CONCLUSION: The overall adjusted incidence rate of abdominal injuries remained stable. Age at presentation increased by over a decade, more often presenting with pre-existing comorbidities (ASA 2 and 3). The proportion of polytrauma patients was significantly reduced over time. Mortality rates were declining, although not statistically significant.

Changing from a two-tiered to a one-tiered trauma team activation protocol: a before-after observational cohort study investigating the clinical impact of undertriage.

BACKGROUND: The aim of this study was to compare the effect of the change in TTA protocol from a two-tier to one-tier, with focus on undertriage and mortality. MATERIAL AND METHODS: A before-after observational cohort study based on data extracted from the Stavanger University Hospital Trauma registry in the transition period from two-tier to a one-tier TTA protocol over two consecutive 1-year periods (2017-2018). Comparative analysis was done between the two time-periods for descriptive characteristics and outcomes. The main outcomes of interest were undertriage and mortality. RESULTS: During the study period 1234 patients were included in the registry, of which 721 (58%) were in the two-tier and 513 (42%) in the one-tier group. About one in five patients (224/1234) were severely injured (ISS > 15). Median age was 39 in the two-tier period and 43 years in the one-tier period (p = 0.229). Median ISS was 5 for the two-tier period vs 9, in the one-tier period (p = 0.001). The undertriage of severely injured patients in the two-tier period was 18/122 (15%), compared to 31/102 (30%) of patients in the one-tier period (OR = 2.5; 95% CI 1.8-4.52). Overall mortality increased significantly between the two TTA protocols, from 2.5 to 4.7% (p = 0.033), OR 0.51 (0.28-0.96) CONCLUSION: A protocol change from two-tiered TTA to one-tiered TTA increased the undertriage in our trauma system. A two-tiered TTA may be beneficial for better patient care.

Clinical patterns of presentation and attenuated inflammatory response in octo- and nonagenarians with perforated gastroduodenal ulcers.

BACKGROUND: Perforated gastrodudenal ulcer (PGDU) is an operative emergency with high mortality rates. The growing elderly population increasingly presents with need for geriatric acute operative care. Current knowledge of age-specific characteristics in presentation, diagnosis, and outcome for PGDU in the elderly is scarce. METHODS: We reviewed a consecutive, population-based cohort of patients with PGDU, octa- and nonagenarians were compared with younger patients for variation in patterns of presentation and outcomes. Patterns and outcomes observed included 30-day mortality, serious complications (Clavien-Dindo 3 and 4), and duration of stay. RESULTS: Of the 244 patients, 127 were women (52%); median age was 68 years; and 59 patients (24.2%) were ≥80 years. Two thirds had gastric ulcers (n = 168; 67.2%). On admission, hemoglobin levels, white blood cell count, and serum levels of C-reactive protein, bilirubin, and albumin differed significantly between the age groups. Diagnosis, treatment, and the occurrence of severe complications did not differ with age. The median hours of delay to definitive treatment did not differ significantly for all ages, but patients ≥80 years had a greater proportion (44.1% compared with 25.8%) of delay >12 hours (odds ratio 2.26, 95% confidence interval 1.22-4.17; P = .008). Overall mortality was 38 (15.6%); no deaths occurred in patients <55 years. Over one half of deaths occurred in those ≥80 years (odds ratio 4.76, 2.30-9.83; P < .001). Duration of hospital stay was significantly greater in elderly survivors, and fewer were discharged within a week. CONCLUSION: Octa- and nonagenarians with PGDU present with fewer signs of peritonitis and have an attenuated inflammatory response. The very elderly have twice the risk of long delays to definitive treatment and almost 5 times increased risk of mortality.

What is the best predictor of mortality in perforated peptic ulcer disease? A population-based, multivariable regression analysis including three clinical scoring systems.

BACKGROUND: Mortality rates in perforated peptic ulcer (PPU) have remained unchanged. The aim of this study was to compare known clinical factors and three scoring systems (American Society of Anesthesiologists (ASA), Boey and peptic ulcer perforation (PULP)) in the ability to predict mortality in PPU. MATERIAL AND METHODS: This is a consecutive, observational cohort study of patients surgically treated for perforated peptic ulcer over a decade (January 2001 through December 2010). Primary outcome was 30-day mortality. RESULTS: A total of 172 patients were included, of whom 28 (16 %) died within 30 days. Among the factors associated with mortality, the PULP score had an odds ratio (OR) of 18.6 and the ASA score had an OR of 11.6, both with an area under the curve (AUC) of 0.79. The Boey score had an OR of 5.0 and an AUC of 0.75. Hypoalbuminaemia alone (≤37 g/l) achieved an OR of 8.7 and an AUC of 0.78. In multivariable regression, mortality was best predicted by a combination of increasing age, presence of active cancer and delay from admission to surgery of >24 h, together with hypoalbuminaemia, hyperbilirubinaemia and increased creatinine values, for a model AUC of 0.89. CONCLUSION: Six clinical factors predicted 30-day mortality better than available risk scores. Hypoalbuminaemia was the strongest single predictor of mortality and may be included for improved risk estimation.

Scoring systems for outcome prediction in patients with perforated peptic ulcer.

BACKGROUND: Patients with perforated peptic ulcer (PPU) often present with acute, severe illness that carries a high risk for morbidity and mortality. Mortality ranges from 3-40% and several prognostic scoring systems have been suggested. The aim of this study was to review the available scoring systems for PPU patients, and to assert if there is evidence to prefer one to the other. MATERIAL AND METHODS: We searched PubMed for the mesh terms "perforated peptic ulcer", "scoring systems", "risk factors", "outcome prediction", "mortality", "morbidity" and the combinations of these terms. In addition to relevant scores introduced in the past (e.g. Boey score), we included recent studies published between January 2000 and December 2012) that reported on scoring systems for prediction of morbidity and mortality in PPU patients. RESULTS: A total of ten different scoring systems used to predict outcome in PPU patients were identified; the Boey score, the Hacettepe score, the Jabalpur score the peptic ulcer perforation (PULP) score, the ASA score, the Charlson comorbidity index, the sepsis score, the Mannheim Peritonitis Index (MPI), the Acute physiology and chronic health evaluation II (APACHE II), the simplified acute physiology score II (SAPS II), the Mortality probability models II (MPM II), the Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity physical sub-score (POSSUM-phys score). Only four of the scores were specifically constructed for PPU patients. In five studies the accuracy of outcome prediction of different scoring systems was evaluated by receiver operating characteristics curve (ROC) analysis, and the corresponding area under the curve (AUC) among studies compared. Considerable variation in performance both between different scores and between different studies was found, with the lowest and highest AUC reported between 0.63 and 0.98, respectively. CONCLUSION: While the Boey score and the ASA score are most commonly used to predict outcome for PPU patients, considerable variations in accuracy for outcome prediction were shown. Other scoring systems are hampered by a lack of validation or by their complexity that precludes routine clinical use. While the PULP score seems promising it needs external validation before widespread use.

Epidemiology of perforated peptic ulcer: age- and gender-adjusted analysis of incidence and mortality.

AIM: To investigate the epidemiological trends in incidence and mortality of perforated peptic ulcer (PPU) in a well-defined Norwegian population. METHODS: A retrospective, population-based, single-center, consecutive cohort study of all patients diagnosed with benign perforated peptic ulcer. Included were both gastric and duodenal ulcer patients admitted to Stavanger University Hospital between January 2001 and December 2010. Ulcers with a malignant neoplasia diagnosis, verified by histology after biopsy or resection, were excluded. Patients were identified from the hospitals administrative electronic database using pertinent ICD-9 and ICD-10 codes (K25.1, K25.2, K25.5, K25.6, K26.1, K26.2, K26.5, K26.6). Additional searches using appropriate codes for relevant laparoscopic and open surgical procedures (e.g., JDA 60, JDA 61, JDH 70 and JDH 71) were performed to enable a complete identification of all patients. Patient demographics, presentation patterns and clinical data were retrieved from hospital records and surgical notes. Crude and adjusted incidence and mortality rates were estimated by using national population demographics data. RESULTS: In the study period, a total of 172 patients with PPU were identified. The adjusted incidence rate for the overall 10-year period was 6.5 per 100 000 per year (95%CI: 5.6-7.6) and the adjusted mortality rate for the overall 10-year period was 1.1 per 100 000 per year (95%CI: 0.7-1.6). A non-significant decline in adjusted incidence rate from 9.7 to 5.6 occurred during the decade. The standardized mortality ratio for the whole study period was 5.7 (95%CI: 3.9-8.2), while the total 30-d mortality was 16.3%. No difference in incidence or mortality was found between genders. However, for patients ≥ 60 years, the incidence increased over 10-fold, and mortality more than 50-fold, compared to younger ages. The admission rates outside office hours were high with almost two out of three (63%) admissions seen at evening/night time shifts and/or during weekends. The observed seasonal variations in admissions were not statistically significant. CONCLUSION: The adjusted incidence rate, seasonal distribution and mortality rate was stable. PPU frequently presents outside regular work-hours. Increase in incidence and mortality occurs with older age.

Trends in diagnosis and surgical management of patients with perforated peptic ulcer.

INTRODUCTION: While the laparoscopic treatment of perforated peptic ulcers (PPU) has been shown to be feasible and safe, its implementation into routine clinical practice has been slow. Only a few studies have evaluated its overall utility. The aim of this study was to investigate changes in surgical management of PPU and associated outcomes. MATERIAL AND METHODS: The study was a retrospective, single institution, population-based review of all patients undergoing surgery for PPU between 2003 and 2009. Patient demographics, diagnostic evaluation, management, and outcomes were evaluated. RESULTS: Included were 114 patients with a median age of 67 years (range, 20-100). Women comprised 59% and were older (p < 0.001), had more comorbidities (p = 0.002), and had a higher Boey risk score (p = 0.036) compared to men. Perforation location was gastric/pyloric in 72% and duodenal in 28% of patients. Pneumoperitoneum was diagnosed by plain abdominal x-ray in 30 of 41 patients (75%) and by abdominal computerized tomography (CT) in 76 of 77 patients (98%; p < 0.001).Laparoscopic treatment was initiated in 48 patients (42%) and completed in 36 patients (75% of attempted cases). Laparoscopic treatment rate increased from 7% to 46% during the study period (p = 0.02). Median operation time was shorter in patients treated via laparotomy (70 min) compared to laparoscopy (82 min) and those converted from laparoscopy to laparotomy (105 min; p = 0.017). Postoperative complications occurred in 56 patients (49%). Overall 30-day postoperative mortality was 16%. No statistically significant differences were found in morbidity and mortality between open versus laparoscopic repair. CONCLUSION: This study demonstrates an increased use of CT as the primary diagnostic tool for PPU and of laparoscopic repair in its surgical treatment. These changes in management are not associated with altered outcomes.

Endoscopy, morphology, morphometry and molecular markers: predicting cancer risk in colorectal adenoma.

The evaluation of short- and long-term risk for developing cancer in patients with colorectal adenomas is controversial. Good, reliable predictors of cancer risk in any adenoma are currently lacking and are limited to adenoma size, number and histologic type. In fact, the evaluation of any adenoma or precancer lesion (e.g., hyperplastic polyps, serrated adenoma or aberrant crypt foci) within the colorectum may be assessed by a number of techniques ranging from direct visualization through the endoscope, to microscopic assessment, and to evaluation at the molecular level. Emerging techniques may yield improved methods of adenoma risk-assessment in the near future. For one, newer endoscopy technologies include chromoendoscopy or endocytoscopy, which now render endoscopists able to resolve the surface and subsurface mucosa at cellular resolution in vivo and in real time - thus, bringing the microscope to the patient's bedside. This new era in endoscopic imaging is dubbed 'histoendoscopy'. Further, while traditional views of classifying protruding and sessile lesions include those of Haggitt, the sm-classification, the Japanese and the so-called Vienna classifications to evaluate neoplasia, the development of new molecular techniques may give way to new methods of classifying preneoplasia and precancerous lesions. This review discusses some pros and cons of risk evaluation technologies in the colorectal tract by endoscopy, microscopy, and quantitative and molecular features. The morphometry-based studies performed over the past decades for the quantitative assessment of cellular and nuclear features within adenomas have failed to yield results amenable for clinical translation and are unlikely to improve further and gain widespread use with current technology. Rather, emerging knowledge of pathway-specific markers through the outlining of a molecular classification will likely be the basis for improved detection and diagnosis. The emerging genomic and proteomic technologies allowing for noninvasive tests to detect (asymptomatic) cancer and neoplasia are discussed. Lastly, the importance of recognizing bias and pitfalls and the adherence to guidelines for biomarker research are addressed.