Natural History of Perianal Crohn's Disease: Long-term Follow-up of a Population-Based Cohort.

BACKGROUND AND AIMS: The natural history of perianal Crohn's disease (PCD) remains poorly described and is mainly based on retrospective studies from referral centers. The aim of this study was to assess the incidence, outcomes and predictors of the onset of PCD. METHODS: All incident cases of patients diagnosed with possible CD were prospectively registered from 1994 to 1997 in Brittany, a limited area in France. At diagnosis, the clinical features of perianal disease were recorded. All patient charts were reviewed from the diagnosis to the last clinic visit in 2015. RESULTS: Among the 272 out of 331 incident CD patients followed up, 51 (18.7%) patients had PCD at diagnosis. After a mean follow-up of 12.8 years, 93 (34%) patients developed PCD. The cumulative probabilities of perianal CD occurrence were 22%, 29%, and 32% after 1 year, 5 years, and 10 years, respectively. The cumulative probabilities of anal ulceration were 14%, and 19% after 1 year and 10 years, respectively. Extraintestinal manifestations were associated with the occurrence of anal ulceration. The cumulative probabilities of fistulizing PCD were 11%, 16%, and 19% after 1 year, 5 years, and 10 years, respectively. Extraintestinal manifestations, rectal involvement and anal ulceration were predictors of fistulizing PCD. The cumulative probability of developing anal stricture was 4% after 10 years. CONCLUSIONS: PCD is frequently observed during CD, in approximately one-third of patients. These data underline the need for targeted therapeutic research on primary perianal lesions (proctitis, anal ulceration) to avoid the onset of fistulizing perianal disease.

Significant decrease in interval colorectal cancer incidence after implementing immunochemical testing in a multiple-round guaiac-based screening programme.

BACKGROUND AND AIMS: We aimed to evaluate the effects of switching to faecal immunochemical testing (FIT) on the cumulative 2-year incidence rate of interval cancers, interval cancer rate and test sensitivity within a mature population-based colorectal cancer screening programme consisting of six rounds of biennial guaiac faecal occult blood testing (gFOBT). METHODS: The FIT results were compared with those of gFOBT used in each of the previous two rounds. For the three rounds analysed, 279,041 tests were performed by 156,186 individuals. Logistic regression analysis was used to determine interval cancer risk factors (Poisson regression) and to compare the sensitivity of FIT to gFOBT. RESULTS: There were 612 cases of screen-detected cancers and 209 cases of interval cancers. The sex- and age-adjusted cumulative 2-year incidence rates of interval cancers were 55.7 (95% CI, 45.3-68.5), 42.4 (95% CI, 32.6-55.2) and 15.8 (95% CI, 10.9-22.8) per 100,000 person-years after the last two rounds of gFOBT and FIT, respectively. The FIT/gFOBT incidence rate ratio was 0.38 [95% CI, 0.27-0.54] (P < 0.001). Sex- and age-adjusted sensitivity was significantly higher with FIT than with gFOBT (OR = 6.70 [95% CI, 4.48-10.01], P < 0.0001). CONCLUSIONS: This population-based study revealed a dramatic decrease in the cumulative incidence rates of interval cancers after switching from gFOBT to FIT. These data provide an additional incentive for countries still using gFOBT to switch to FIT.

Reappraisal of the characteristics, management, and prognosis of intramucosal colorectal cancers and their comparison with T1 carcinomas.

BACKGROUND AND AIMS: The recent description of "invasive" forms of intramucosal carcinoma (IMC) has rekindled interest in studying the characteristics, management, and prognosis of IMCs and comparing them with T1 colorectal cancers (CRCs). METHODS: This population-based study included 282 cases of IMC and 207 cases of T1 CRC diagnosed by colonoscopy after a positive fecal blood test through a screening program. RESULTS: IMC presented mainly in the form of pedunculated polyps (68.4%) located in the distal colon (69.9%) ≥20 mm in size (60.6%). IMCs were resected endoscopically in 227 (80.5%) patients and surgically resected in 55 (19.5%) patients. Surgical patients had more right-sided, more sessile, and larger lesions. There was no sign of lymphovascular invasion. Compared with T1 CRCs, IMCs demonstrated lower rates of sessile polyps (31.6% vs 49.8%, P < .0001), primary and ultimate surgical treatment (19.5% vs 39.1% and 19.9% vs 78.7%, P < .0001, respectively), lymph node metastasis in surgical patients (0% vs 9.5%, P = .041), cancer recurrence and cancer-related mortality (0% vs 5.6% and 0% vs 2.5%, respectively), and bleeding after endoscopic resection (1.8% vs 8.7%, P = .001). By multivariate analysis of the pooled cohort (IMC + T1 CRC, n = 489), the factors significantly associated with first-line surgery were shown to be polyp characteristics and the gastroenterologist who performed the colonoscopy. CONCLUSIONS: IMCs account for a quarter of all screening-detected CRCs. They have an excellent prognosis regardless of whether endoscopic or surgical treatment is performed. IMCs differ significantly from T1 carcinomas in terms of management and prognosis.

Frequency of and risk factors for the surgical resection of nonmalignant colorectal polyps: a population-based study.

BACKGROUND AND STUDY AIMS: The management of patients with colon polyps who are referred to surgery remains uncharacterized in a population-based setting. The aims of this study were to determine the frequency, risk factors, and outcomes of patients referred for surgical resection of colorectal polyps. PATIENTS AND METHODS: All patients who underwent a colonoscopy for positive fecal occult blood test in the setting of a population-based colorectal cancer screening program in France between 2003 and 2012 were analyzed. The primary outcome was the proportion of patients undergoing colorectal surgery for polyps without invasive carcinoma. Logistic regression analysis was applied to identify risk factors for surgical resection. RESULTS: Among 4251 patients with at least one colorectal polyp, 175 (4.1 %) underwent colorectal surgery. Risk factors for surgery included size, proximal polyp location, advanced histology (villous or high grade dysplasia), the endoscopy center, and colonoscopy performed during the first half of the study period. Subgroup analysis of 3475 colonoscopies performed by 22 endoscopists who performed at least 50 colonoscopies during the study period, identified the endoscopist as an additional risk factor. The adjusted proportions of referrals to surgery ranged from 0 to 46.6 % per endoscopist for polyps ≥ 20  mm (median 20.2 %). Overall, surgical complications occurred in 24.0 %, and one patient died following surgery (0.5 %). None of the 175 patients who underwent surgery were referred to a tertiary endoscopic center prior to surgery. CONCLUSIONS: In this population-based study, 4.1 % of patients with nonmalignant polyps were referred for surgical resection. The endoscopist was one important factor that was associated with surgical referral. To further decrease the proportion of inappropriate surgery in patients, endoscopists should refer their patients with large or difficult polyps to expert endoscopists prior to surgery.

Crohn's disease: is there any link between anal and luminal phenotypes?

PURPOSE: Perianal Crohn's disease (CD) encompasses a variety of lesion similar to luminal disease, which are usually not distinctly assessed. Links between luminal and perianal CD phenotype remains therefore underreported, and we aimed to describe both luminal and perianal phenotype and their relationships. METHODS: From January 2007, clinical data of all consecutive patients with CD seen in a referral center were prospectively recorded. Data recorded until October 2011 were extracted and reviewed for study proposal. RESULTS: A total of 282 patients (M/F, 108/174; aged 37.8 ± 16.2 years) were assessed that included 154 cases (54.6%) with anal ulceration, 118 cases (41.8%) with fistula, 49 cases (17.4%) with stricture, and 94 cases without anal lesion (33.3%). Anal ulcerations were associated with fistulas (N = 87/154) in more than half of patients (56.5%) and were isolated in 55 patients (35.7%). Most of strictures (94%) were associated with other lesions (N = 46/49). Harvey-Bradshaw score was significantly higher in patients with ulcerations (p < 0.001) as compared to those with perianal fistulas (p = 0.15) or with anal strictures (p = 0.16). Proportions of complicated behavior (fistulizing or stricturing) of luminal CD were similar according to anal lesions: anal fistulas were not significantly associated to penetrating Montreal phenotype (N = 4/31 p = 0.13) as well as anal stricture and stricturing Montreal phenotype (N = 3/49, p = 0.53). CONCLUSIONS: The phenotype of luminal disease does not link with the occurrence and the phenotype of perianal Crohn's disease. Anal ulcerations denote a more severe disease on both luminal and perianal locations and should consequently be taking into account in physician decision-making.

Long-term outcome of perianal fistulizing Crohn's disease treated with infliximab.

BACKGROUND & AIMS: Little is known about the long-term efficacy of infliximab for patients with fistulizing perianal Crohn's disease. We evaluated outcomes and predictors of outcomes in these patients. METHODS: The medical records of 156 patients treated with infliximab for fistulizing perianal Crohn's disease at 2 referral centers from 1999 through 2010 were reviewed through September 2011. Cumulative probabilities of fistula closure and recurrence were estimated by using the Kaplan-Meier method. Predictors of outcomes were identified by using a Cox proportional hazards model. RESULTS: When infliximab treatment began, only 17.9% of patients had a simple fistula; seton drainage was performed for 97 patients (62%). Concomitant immunosuppressants were given to 90 patients (56%). After a median follow-up period of 250 weeks, 108 patients (69%) had at least 1 fistula closure. Cumulative probabilities of first fistula closure were 40% and 65% at 1 and 5 years, respectively. Factors that predicted fistula closure were ileocolonic disease (hazard ratio [HR] = 1.88), concomitant immunosuppressants (HR = 2.58), duration of seton drainage <34 weeks (HR = 2.31), and long duration of infliximab treatment (HR = 1.76). Of the 108 patients with fistula closure, cumulative probabilities of first fistula recurrence were 16.6% and 40.1% at 1 and 5 years, respectively. Forty-four patients (28.9%) developed an abscess during follow-up. A number of infliximab infusions greater than 19 was associated with less abscess recurrence (HR = 0.33). At the maximal follow-up time, 55% of patients had fistula closure. CONCLUSIONS: About two-thirds of patients with fistulizing perianal Crohn's disease had fistula closure, and one-third had fistula recurrence after infliximab initiation. Combination therapy, duration of seton drainage less than 34 weeks, and long-term treatment with infliximab were associated with better outcomes.

No surgery for full-thickness rectal prolapse: what happens with continence?

BACKGROUND: Surgery is the only validated means of treating overt rectal prolapses, but both patients and physicians may decline or postpone the surgical approach. However, little is known on the functional outcome of nonoperated rectal prolapse. The aim of the present study was to highlight the natural history of overt rectal prolapse in patients for whom surgery was avoided or delayed. PATIENTS AND METHODS: A total of 206 patients complaining of full-thickness rectal prolapse were referred to a single institution that provided anorectal physiology for functional anorectal disorders. Standardized questionnaires, anorectal manometry, endosonography, and evacuation proctography constituted a prospective database. Fecal incontinence was evaluated with the Cleveland Clinic score (CCIS), and constipation was evaluated with the Knowles Eccersley Scott Symptom score (KESS). RESULTS: Forty-two nonoperated patients (mean age: 61 ± 16 years) were compared to those of operated patients paired according to age and gender: the mean follow-up was 44 ± 26 months. The two groups had a similar past-history, follow-up, stool frequency, and main complaints, but lower quantified symptomatic scores and a better quality of life were reported in the nonsurgical group. At the end of follow-up, the nonsurgical group did not show any variation in CCI and KESS scores. By contrast, these two scores significantly improved in the rectopexy group. Sixteen nonoperated patients experienced a degradation of their continence status with an average increase of 5 ± 4.3 points of the CCIS. The patients with a CCIS <7 at referral were likely to deteriorate as compared to those having a higher score. Patients with a symptom history longer than 4 years never improved and in two-thirds continence deteriorated throughout the follow-up. CONCLUSION: In the absence of the surgical option, patients with a 4-year duration of rectal prolapse and those with mild incontinence had no chance of improvement. These findings may be taken into account when surgery of rectal prolapse is not chosen.

Impact of age over 75 years on outcomes after pancreaticoduodenectomy.

BACKGROUND: The risks associated with pancreaticoduodenectomy (PD) in elderly patients continue to be debated. The aim of our study was to assess the incidence of death and postoperative complications following PD and identify the risk factors in patients >75 y. STUDY DESIGN: All patients who underwent PD between January 2000 and September 2009 were analyzed retrospectively. Patients were divided into two groups according to age (Group 1: patients aged <75 y, and Group 2: patients aged ≥ 75 y). Morbidity and perioperative mortality risk factors were analyzed using univariate and multivariate analyses. RESULTS: Among the 314 patients, 273 were included in Group 1 (sex ratio 1.4) and 41 in Group 2 (sex ratio 1). In multivariate analysis, postoperative hemorrhage (PH) (OR 6.61, IC95% [1.96; 22.31], P = 0.002) and age >75 y proved to be predictive factors for mortality (OR 11.04, IC95% [2.57; 47.49], P = 0.001). When compared with Group 1, Group 2 was associated with increased postoperative deaths (24.4% versus 3.66%, P < 0.001) and pancreatic fistulas (26.8% versus 13.2%, P = 0.041), in particular, Grade C fistulas (14.6% versus 4.4%, P = 0.023). In multivariate analysis, only PH proved to be an independent predictive factor for mortality (OR 12.9, IC95% [1.07; 155.5], P = 0.04). CONCLUSIONS: PD in elderly patients aged over 75 y appears to be associated with an increased risk of postoperative death and pancreatic fistula. No single preoperative factor made it possible to predict this risk.

Long-term outcomes and predictors of disabling disease in a population-based cohort of patients with incident Crohn's disease diagnosed between 1994 and 1997.

BACKGROUND: The identification of early prognostic factors during Crohn's disease (CD) remains needed for physician decision-making to minimize structural bowel damage, which this study aimed to assess in a population-based setting. METHODS: All incident cases of CD were prospectively registered from 1994 to 1997 in Brittany, a limited area of France. All charts of patients were reviewed from the diagnosis to the last clinic visit in 2015. Disabling CD course was defined according to the Saint-Antoine criteria. RESULTS: Among the 331 incident cases of CD, 272 (82%) were followed-up for a median time of 12.8 years. The cumulative probability of developing stricturing or fistulizing CD was 66% at 15 years, and 107 (39%) patients underwent surgery. The cumulative probabilities of immunosuppressant and TNF antagonist use at 15 years were 37% and 22%, respectively. The cumulative risks for disabling disease and bowel damage were 74% and 71% at 15 years, respectively. Systemic symptoms and perianal lesions at diagnosis were independently associated with a disabling disease course. Perianal disease and short disease extension were associated with the onset of bowel damage. Deep ulcers was not predictive of any outcome. CONCLUSIONS: A disabling disease course and bowel damage occurred early in the course of CD, which suggests the need for early diagnosis and early treatment, particularly for patients with systematic symptoms and perianal disease.

Neoplasia detection rates after positive fecal occult blood test results are not affected by endoscopy center: a population-based study.

BACKGROUND: We previously showed a significant variability in adenoma detection among colonoscopists who were participating in a mass screening program. The reasons for such variability remain largely unknown. OBJECTIVE: To study intercenter variations in neoplasia detection. DESIGN AND SETTING: Secondary analyses of colonoscopy findings from the 2 first rounds of a French screening program: logistic regressions and repeated-measures analyses of variance. MATERIAL: A total of 3487 colonoscopies performed by all 19 endoscopists who performed 30 examinations or more per round at 8 centers (6 private, 2 public). MAIN OUTCOME MEASUREMENTS: Probabilities of detecting 1, 2, or 3 or more adenomas, 1 adenoma 10 mm or larger, or colorectal cancer, as well as the corresponding adjusted (for patient age and sex) per-center detection rates. RESULTS: Endoscopy centers were not significant predictors of the probability of detecting any category of neoplasia with the exception of the 2 adenomas or more category (P < .005). The ranges of the adjusted detection rates for each of these categories were 33.1% to 43.1%, 11.1% to 21.6%, 3.6% to 8.1%, 16.3% to 23.6%, and 8.3% to 12.6%, respectively. When the colonoscopies that were performed by the 11 endoscopists who performed 30 examinations or more per center in 2 or more centers were separately analyzed, no intercenter statistically significant variability was observed with the exception of 1 endoscopist and the 1 adenoma category. In a subgroup of 1100 colonoscopies performed by 6 endoscopists who were working at the same 3 centers, intercenter variability was not statistically significant. LIMITATIONS: Type II error because of sample sizes. CONCLUSIONS: In our setting, intercenter variability did not explain interendoscopist variability for neoplasia detection rate.

Measurement of adenoma detection and discrimination during colonoscopy in routine practice: an exploratory study.

BACKGROUND: Measuring neoplasia yield is a priority in the quality improvement process for colonoscopy. However, neither the most appropriate quality indicator nor the standard threshold has been established. OBJECTIVE: To determine the most appropriate quality indicators to assess the yield of routine colonoscopy. DESIGN: Retrospective. SETTING: Population-based colorectal cancer screening program in 3 French administrative areas. SUBJECTS: One hundred gastroenterologists and their average-risk asymptomatic patients aged 50 to 74 years undergoing colonoscopy for positive guaiac-based fecal occult blood test results. MAIN OUTCOME MEASUREMENTS: Comparison of several indicators, mainly the adenoma detection rate (ADR) and polyp detection rate (PDR), the mean number of adenomas per colonoscopy (MNA) and mean number of polyps (MNP) and the proportion of adenomas among polyps (PAP). RESULTS: Correlations were good between the ADR and PDR (Pearson coefficient r = 0.88 [95% CI, 0.78-0.94]) and between MNA and MNP (r = 0.89 [95% CI, 0.79-0.94]) (P < .0001 for both). Gastroenterologists were classified as higher or lower detectors in comparison with the lower limit of the 95% confidence interval of the median value for each indicator. The MNP (MNA) provided better discrimination than the PDR (ADR). Concordance between classifications of gastroenterologists according to their MNA and MNP was excellent (κ = 0.89). PAP varied dramatically from 38% to 95% between gastroenterologists and was very poorly correlated with the ADR (r = -0.27 [95% CI, -0.54 to 0.07; P = .11]) and the MNA (r = 0.03 [95% CI, -0.29 to 0.36; P = .88]). LIMITATIONS: Some factors influencing the neoplasia yield were not taken into account. CONCLUSIONS: The MNP could replace the ADR for the assessment of adenoma detection in routine practice. A separate indicator, PAP, would be necessary to assess adenoma discrimination ability.

Surgical rather than endoscopic resection of early-stage colorectal cancers promotes excessive imaging surveillance.

BACKGROUND AND AIMS: Imaging surveillance after curative resection of colorectal cancer (CRC) is debated, particularly in cases of early-stage CRC. The aim of this study was to retrospectively analyze whether and how patients with screened stage 0 and stage 1 CRC were monitored by imaging. METHODS: A cohort of patients with stage 0 (intramucosal) or stage 1 (T1N0) CRC detected from 2003 to 2015 through the French national screening programme was included. All imaging findings were recorded. Statistical analyses were performed for the entire cohort (n = 450) and separately for the two groups (stage 0 n = 268, stage 1 n = 182). Factors associated with imaging surveillance, including the patient's referring gastroenterologist, were determined by logistic regression. RESULTS: A total of 450 patients were followed up for 6.6 ±â€¯3.9 years. Imaging surveillance was performed for 159 (35.3%), more often for those with stage 1 (66.5%) than stage 0 (14.2%) tumours (p < 0.0001). Within the stage 1 group, 17 of the 47 patients (36.2%) treated by local (endoscopic or surgical transanal) resection alone were followed up by imaging monitoring. Factors significantly associated with surveillance in the entire cohort were the gastroenterologist assigned to the patient (p < 0.0001) and surgical vs endoscopic resection (OR = 39.0, p < 0.0001). The histological risk of lymph node metastasis was not significantly associated with imaging monitoring for stage 1 patients. Of the 5 patients who developed distant metastasis during follow-up, one was diagnosed through imaging surveillance. CONCLUSION: This study demonstrates excessive imaging surveillance for early-stage cancers. The use of surgical over endoscopic tumour resection could promote unnecessary surveillance.

Variations between endoscopists in rates of detection of colorectal neoplasia and their impact on a regional screening program based on colonoscopy after fecal occult blood testing.

BACKGROUND: There are few data about the performance variability among endoscopists participating to nationwide or regionwide colorectal cancer screening programs. OBJECTIVE: To assess the variability of neoplasia detection rates among endoscopists participating in a regional colorectal cancer screening program based on colonoscopy after biennial fecal occult blood testing (FOBT). DESIGN: Two rounds of colonoscopy were performed: round 1 took place in 2003 and 2004, and round 2 took place in 2005 and 2006. Secondary analysis of colonoscopy findings from the first 2 rounds was performed by using data drawn from all endoscopists who performed more than 30 colonoscopies in each round. Detection rates were adjusted for patient age and sex, and logistic regression analyses were conducted including these 2 variables and round number (1 or 2). SETTING: District of Ille-et-Vilaine in Brittany (population >900,000) between 2003 and 2007. MAIN OUTCOME MEASUREMENTS: The per-endoscopist adjusted rates of colonoscopies with at least 1, 2, or 3 adenomas, 1 adenoma 10 mm or larger, or a cancer. RESULTS: Among the 18 endoscopists who performed 3462 colonoscopies, the adjusted detection rates were in the following ranges: at least 1 adenoma, 25.4% to 46.8%; 2 adenomas, 5.1% to 21.7%; 3 adenomas, 2.7% to 12.4%; 1 adenoma 10 mm or larger, 14.2% to 28.0%; and cancer, 6.3% to 16.4%. Multivariate analyses showed that the endoscopist was not an independent predictor of cancer detection, but was an independent predictor of detecting adenomas, regardless of category; the R(2) of the models ranged from 6% to 13% only. LIMITATIONS: Other factors known to influence colorectal neoplasia occurrence and withdrawal time could not be taken into account. CONCLUSIONS: In a screening program with a high compliance rate with colonoscopy after FOBT, interendoscopist variability had no effect on cancer detection, but did influence identification of adenomas. The clinical impact of such findings merits further evaluation.

Removal of transanastomotic pancreatic stent tubes after pancreaticoduodenectomy: a new role for double-balloon enteroscopy.

BACKGROUND: Endoscopic interventions are usually very challenging in patients with anatomic changes caused by earlier GI surgery. The recent development of the double-balloon enteroscopy (DBE) system creates an opportunity to reach the biliary tract and the pancreatic duct in postsurgical conditions. OBJECTIVE: To report a further application of DBE in surgical patients; namely, extraction of pancreatic stents placed in pancreaticojejunal anastomosis during pancreaticoduodenectomy. DESIGN: Two case reports. SETTING: A single-center experience in a tertiary-care unit. PATIENTS AND INTERVENTIONS: Two patients who underwent Whipple resection with Roux-en-Y reconstruction presented with migration of pancreatic stent tubes inserted in pancreaticojejunal anastomoses. Stents had migrated to the end of the afferent limb and were causing abdominal pain. Because extraction failed by using conventional endoscopy, we used the DBE system. MAIN OUTCOME MEASURES: Successful extraction of the stents. RESULTS: Stents were successfully removed in both patients with no complications. After 1 year of follow-up, the patients remained free of painful symptoms. LIMITATIONS: Small volume case series. CONCLUSIONS: Double-balloon enteroscopy is a reliable way to investigate and treat patients with postsurgical altered anatomy. Here, we report the successful removal of pancreatic stents migrating into the jejunal loop through pancreaticojejunal anastomosis.

Yield of high-grade dysplasia based on polyp size detected at colonoscopy: a series of 2295 examinations following a positive fecal occult blood test in a population-based study.

PURPOSE: The aim was to determine the rate of high-grade dysplasia among patients with all adenomas, and its prevalence in patients with adenomas of different sizes in a well-defined population-based study. POPULATION AND METHODS: We performed a secondary analysis of the 2295 colonoscopies performed following a positive fecal occult blood test result during the first round of colorectal cancer screening in one French district. The rates of high-grade dysplasia were calculated for 3 size categories of adenoma (diminutive, or=10 mm). Predictive factors for high-grade dysplasia were assessed by univariate and multivariate analyses. RESULTS: A total of 1284 adenomas were detected in 784 subjects. High-grade dysplasia was present in 32.1% of the 784 subjects and in 2.7%, 16.0%, and 51.1% of those whose adenomas were diminutive, small, and large, respectively. Among subjects with no more than 2 small adenomas, the proportion of those with high-grade dysplasia was 12.4%. Both adenoma size and a villous component within adenomas were found to be independent predictive factors for high-grade dysplasia by multivariate analysis. CONCLUSIONS: Because of the high rate of high-grade dysplasia among small adenomas, our results reinforce the need to remove all small adenomas detected at colonoscopy. Furthermore, the results suggest that opting for CT colonography surveillance instead of colonoscopic removal among subjects with one or 2 small polyps revealed by CT colonography would have led to missed high-grade dysplasia in 12.4% of them.

Chronic posterior tibial nerve transcutaneous electrical nerve stimulation (TENS) to treat fecal incontinence (FI).

AIM: Transcutaneous electrical nerve stimulation (TENS) is a possible alternative to sacral nerve stimulation because the neurophysiologic targets might be similar but the former method is non-invasive and cheaper. The aim of the study was to assess both symptom and quality of life (QoL) improvements in patients suffering from severe FI. METHODS: Thirty two patients (M/F, 30/2; age, 61 +/- 13 years) were enrolled in a pilot trial because they suffered from a severe and stable FI (Cleveland Score14.5 +/- 2.8 [11-20]) for a long duration (95 +/- 91 months). TENS was delivered 20 min bis in die at home (Schwa Medico, P3). Assessment was realized at 1, 3, and 6 months with both semi-directive and self-administered questionnaires. Main endpoint was the quantified success rate after 1 month of follow-up. RESULTS: Mean subjective improvement was 26 +/- 30%: 20 (63%) patients reported some degree of improvement and 10 (32%) at least a 25% improvement in fecal incontinence. The Cleveland score significantly decreased at 1 (11 +/- 4; p < 0.001), 3 (11 +/- 5; p < 0.001), and 6 (10 +/- 5; p < 0.001) months. All subscales of QoL were significantly improved after a 3-month period of stimulation. However, constipation score and number of pads did not change. There was no adverse event. CONCLUSION: TENS provides slight improvement in FI. This justifies both neurophysiology assessment and randomized controlled studies before further diffusion of the technique.

Management of T1 colorectal cancers detected at screening colonoscopy: A study from the French national screening programme.

AIM: The main aim of this study was to examine the management strategies that were used and to determine the outcomes (survival and recurrence rate) of screen-detected T1-CRC. METHODS: Medical records from 207 patients with T1-CRC diagnosed through the French national screening programme in one district from 2003 to 2015 were analysed. The 5-year overall, CRC-specific and CRC-free survival were calculated for the whole cohort and for the 3 groups treated by endoscopic resection (ER) alone, ER followed by subsequent surgery (ERSS), and primary surgery (PS). RESULTS: Of the 207 patients, 81 (39%) underwent PS, and 126 (61%) underwent primary ER, of whom 82 (64%) underwent subsequent surgery. The 5-year overall and cancer-specific survival rates were 95.5% (95% CI, 90.8; 97.9) and 98.8% (95% CI, 95.4; 99.7%), respectively. Long-term cancer-specific mortality and recurrence crude rates were 2.4% and 5.6%, respectively. The 5-year CRC-free survival rate was 96.1% (95% CI, 91.8; 98.1%) and did not differ amongst the 3 groups (ER alone, ERSS and PS). CONCLUSION: This study demonstrates the good prognosis of screen-detected T1-CRC, regardless of the treatment strategy used. But, there is a room to improve the screening programme quality with regard to the management of screen-detected CRC.

Switching from guaiac to immunochemical faecal occult blood test increases participation and diagnostic yield of colorectal cancer screening.

BACKGROUND: Compared with the guaiac-faecal occult blood test (gFOBT), faecal immunological tests (FIT) are considered to be more effective for colorectal cancer (CRC) screening. However, only scarce research has examined the outcomes of switching to FIT within a mature gFOBT-based CRC screening programme. METHODS: We reported a 15-year experience of biennial FOBT screening in a well-defined population of approximately one million inhabitants, including six gFOBT-based screening rounds and one round with FIT at the 30 µg Hb/g cut-off. The main outcome measures were screening participation, FOBT positivity and advanced neoplasia detection in each round. RESULTS: In this study, 647 676 screenings were performed in 228 716 different individuals, leading to 17 819 positives and 16 580 follow-up colonoscopies. Compared with the last gFOBT round, switching to FIT led to an increased participation of nearly 20% points, and a fivefold increased detection of CRC and advanced adenoma among invitees (3-fold among attendees). The numbers needed to screen and scope to detect one advanced neoplasia declined from 221 to 66 and from 4.7 to 2.6, respectively. CONCLUSIONS: The present population-based study demonstrated a dramatical increase in the diagnostic yield of advanced neoplasia by switching to FIT within a mature gFOBT-based CRC screening programme.