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BACKGROUNDS AND AIMS: The Mayo endoscopic subscore (MES) is the most popular endoscopic disease activity measure of ulcerative colitis (UC). Artificial intelligence (AI)-assisted colonoscopy is expected to reduce diagnostic variability among endoscopists. However, no study has been conducted to ascertain whether AI-based MES assignments can help predict clinical relapse, nor has AI been verified to improve the diagnostic performance of non-specialists. METHODS: This open-label, prospective cohort study enrolled 110 patients with UC in clinical remission. The AI algorithm was developed using 74713 images from 898 patients who underwent colonoscopy at three centers. Patients were followed up after colonoscopy for 12 months, and clinical relapse was defined as a partial Mayo score >2. A multi-video, multi-reader analysis involving 124 videos was conducted to determine whether the AI system reduced the diagnostic variability among six non-specialists. RESULTS: The clinical relapse rate for patients with AI-based MES = 1 (24.5% [12/49]) was significantly higher (log-rank test, P = 0.01) than that for patients with AI-based MES = 0 (3.2% [1/31]). Relapse occurred during the 12-month follow-up period in 16.2% (13/80) of patients with AI-based MES = 0 or 1 and 50.0% (10/20) of those with AI-based MES = 2 or 3 (log-rank test, P = 0.03). Using AI resulted in better inter- and intra-observer reproducibility than endoscopists alone. CONCLUSIONS: Colonoscopy using the AI-based MES system can stratify the risk of clinical relapse in patients with UC and improve the diagnostic performance of non-specialists.
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BACKGROUND AND AIMS: Image-enhanced endoscopy has attracted attention as a method for detecting inflammation and predicting outcomes in patients with ulcerative colitis (UC); however, the procedure requires specialist endoscopists. Artificial intelligence (AI)-assisted image-enhanced endoscopy may help nonexperts provide objective accurate predictions with the use of optical imaging. We aimed to develop a novel AI-based system using 8853 images from 167 patients with UC to diagnose "vascular-healing" and establish the role of AI-based vascular-healing for predicting the outcomes of patients with UC. METHODS: This open-label prospective cohort study analyzed data for 104 patients with UC in clinical remission. Endoscopists performed colonoscopy using the AI system, which identified the target mucosa as AI-based vascular-active or vascular-healing. Mayo endoscopic subscore (MES), AI outputs, and histologic assessment were recorded for 6 colorectal segments from each patient. Patients were followed up for 12 months. Clinical relapse was defined as a partial Mayo score >2 RESULTS: The clinical relapse rate was significantly higher in the AI-based vascular-active group (23.9% [16/67]) compared with the AI-based vascular-healing group (3.0% [1/33)]; P = .01). In a subanalysis predicting clinical relapse in patients with MES ≤1, the area under the receiver operating characteristic curve for the combination of complete endoscopic remission and vascular healing (0.70) was increased compared with that for complete endoscopic remission alone (0.65). CONCLUSIONS: AI-based vascular-healing diagnosis system may potentially be used to provide more confidence to physicians to accurately identify patients in remission of UC who would likely relapse rather than remain stable.
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Inteligência Artificial , Colite Ulcerativa , Colonoscopia , Recidiva , Humanos , Colite Ulcerativa/diagnóstico , Colite Ulcerativa/patologia , Estudos Prospectivos , Feminino , Masculino , Colonoscopia/métodos , Adulto , Pessoa de Meia-Idade , Mucosa Intestinal/patologia , Mucosa Intestinal/diagnóstico por imagem , Colo/patologia , Colo/diagnóstico por imagem , Colo/irrigação sanguínea , Estudos de Coortes , Curva ROC , Adulto Jovem , Cicatrização , IdosoRESUMO
BACKGROUND & AIMS: Reported rates of delayed bleeding (DB) after endoscopic resection using direct oral anticoagulants (DOACs) are high and heterogeneous. This large-scale multicenter study analyzed cases of DB after colorectal endoscopic submucosal dissection related to various types of DOACs in Japan (the ABCD-J study) with those associated with warfarin. METHODS: We retrospectively reviewed 1019 lesions in patients treated with DOACs and 459 lesions in patients treated with warfarin among 34,455 endoscopic submucosal dissection cases from 47 Japanese institutions between 2012 and 2021. The DB rate (DBR) with each DOAC was compared with that with warfarin. Risk factors for DB in patients treated with DOACs or warfarin were also investigated. RESULTS: The mean tumor sizes in the DOAC and warfarin groups were 29.6 ± 14.0 and 30.3 ± 16.4 mm, respectively. In the DOAC group, the DBR with dabigatran (18.26%) was significantly higher than that with apixaban (10.08%, P = .029), edoxaban (7.73%, P = .001), and rivaroxaban (7.21%, P < .001). Only rivaroxaban showed a significantly lower DBR than warfarin (11.76%, P = .033). In the multivariate analysis, heparin bridging therapy (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.27-3.73, P = .005), rectal location (2.01, 1.28-3.16, P = .002), and procedure time ≥55 minutes (2.43, 1.49-3.95, P < .001) were significant risk factors for DB in the DOAC group. The DB risk in the DOAC group (OR, (95% CI)) was 2.13 (1.30-3.50) and 4.53 (2.52-8.15) for 1 and 2 significant risk factors, respectively. CONCLUSIONS: Dabigatran was associated with a higher DBR than other DOACs, and only rivaroxaban was associated with a significantly lower DBR than warfarin.
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Fibrilação Atrial , Neoplasias Colorretais , Ressecção Endoscópica de Mucosa , Humanos , Varfarina , Rivaroxabana/efeitos adversos , Dabigatrana/efeitos adversos , Japão , Ressecção Endoscópica de Mucosa/efeitos adversos , Estudos Retrospectivos , Hemorragia/induzido quimicamente , Anticoagulantes , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/complicações , Administração Oral , Fibrilação Atrial/complicaçõesRESUMO
OBJECTIVES: Computer-aided characterization (CADx) may be used to implement optical biopsy strategies into colonoscopy practice; however, its impact on endoscopic diagnosis remains unknown. We aimed to evaluate the additional diagnostic value of CADx when used by endoscopists for assessing colorectal polyps. METHODS: This was a single-center, multicase, multireader, image-reading study using randomly extracted images of pathologically confirmed polyps resected between July 2021 and January 2022. Approved CADx that could predict two-tier classification (neoplastic or nonneoplastic) by analyzing narrow-band images of the polyps was used to obtain a CADx diagnosis. Participating endoscopists determined if the polyps were neoplastic or not and noted their confidence level using a computer-based, image-reading test. The test was conducted twice with a 4-week interval: the first test was conducted without CADx prediction and the second test with CADx prediction. Diagnostic performances for neoplasms were calculated using the pathological diagnosis as reference and performances with and without CADx prediction were compared. RESULTS: Five hundred polyps were randomly extracted from 385 patients and diagnosed by 14 endoscopists (including seven experts). The sensitivity for neoplasia was significantly improved by referring to CADx (89.4% vs. 95.6%). CADx also had incremental effects on the negative predictive value (69.3% vs. 84.3%), overall accuracy (87.2% vs. 91.8%), and high-confidence diagnosis rate (77.4% vs. 85.8%). However, there was no significant difference in specificity (80.1% vs. 78.9%). CONCLUSIONS: Computer-aided characterization has added diagnostic value for differentiating colorectal neoplasms and may improve the high-confidence diagnosis rate.
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Pólipos do Colo , Neoplasias Colorretais , Humanos , Pólipos do Colo/diagnóstico , Pólipos do Colo/patologia , Colonoscopia/métodos , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/patologia , Valor Preditivo dos Testes , Computadores , Imagem de Banda Estreita/métodosRESUMO
Objectives: Japanese guidelines include high-grade (poorly differentiated) tumors as a risk factor for lymph node metastasis (LNM) in T1 colorectal cancer (CRC). However, whether the grading is based on the least or most predominant component when the lesion consists of two or more levels of differentiation varies among institutions. This study aimed to investigate which method is optimal for assessing the risk of LNM in T1 CRC. Methods: We retrospectively evaluated 971 consecutive patients with T1 CRC who underwent initial or additional surgical resection from 2001 to 2021 at our institution. Tumor grading was divided into low-grade (well- to moderately differentiated) and high-grade based on the least or predominant differentiation analyses. We investigated the correlations between LNM and these two grading analyses. Results: LNM was present in 9.8% of patients. High-grade tumors, as determined by least differentiation analysis, accounted for 17.0%, compared to 0.8% identified by predominant differentiation analysis. A significant association with LNM was noted for the least differentiation method (p < 0.05), while no such association was found for predominant differentiation (p = 0.18). In multivariate logistic regression, grading based on least differentiation was an independent predictor of LNM (p = 0.04, odds ratio 1.68, 95% confidence interval 1.00-2.83). Sensitivity and specificity for detecting LNM were 27.4% and 84.1% for least differentiation, and 2.1% and 99.3% for predominant differentiation, respectively. Conclusions: Tumor grading via least differentiation analysis proved to be a more reliable measure for assessing LNM risk in T1 CRC compared to grading by predominant differentiation.
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PURPOSE: Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for early gastric cancer. However, perforations may happen and cause peritonitis during ESD. Thus, there is a potential demand for a computer-aided diagnosis system to support physicians in ESD. This paper presents a method to detect and localize perforations from colonoscopy videos to avoid perforation ignoring or enlarging by ESD physicians. METHOD: We proposed a training method for YOLOv3 by using GIoU and Gaussian affinity losses for perforation detection and localization in colonoscopic images. In this method, the object functional contains the generalized intersection over Union loss and Gaussian affinity loss. We propose a training method for the architecture of YOLOv3 with the presented loss functional to detect and localize perforations precisely. RESULTS: To qualitatively and quantitatively evaluate the presented method, we created a dataset from 49 ESD videos. The results of the presented method on our dataset revealed a state-of-the-art performance of perforation detection and localization, which achieved 0.881 accuracy, 0.869 AUC, and 0.879 mean average precision. Furthermore, the presented method is able to detect a newly appeared perforation in 0.1 s. CONCLUSIONS: The experimental results demonstrated that YOLOv3 trained by the presented loss functional were very effective in perforation detection and localization. The presented method can quickly and precisely remind physicians of perforation happening in ESD. We believe a future CAD system can be constructed for clinical applications with the proposed method.
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Colonoscopia , Neoplasias Gástricas , Humanos , Colonoscopia/métodos , Neoplasias Gástricas/cirurgia , Resultado do Tratamento , Estudos RetrospectivosRESUMO
OBJECTIVES: Lymph node metastasis (LNM) prediction for T1 colorectal cancer (CRC) is critical for determining the need for surgery after endoscopic resection because LNM occurs in 10%. We aimed to develop a novel artificial intelligence (AI) system using whole slide images (WSIs) to predict LNM. METHODS: We conducted a retrospective single center study. To train and test the AI model, we included LNM status-confirmed T1 and T2 CRC between April 2001 and October 2021. These lesions were divided into two cohorts: training (T1 and T2) and testing (T1). WSIs were cropped into small patches and clustered by unsupervised K-means. The percentage of patches belonging to each cluster was calculated from each WSI. Each cluster's percentage, sex, and tumor location were extracted and learned using the random forest algorithm. We calculated the areas under the receiver operating characteristic curves (AUCs) to identify the LNM and the rate of over-surgery of the AI model and the guidelines. RESULTS: The training cohort contained 217 T1 and 268 T2 CRCs, while 100 T1 cases (LNM-positivity 15%) were the test cohort. The AUC of the AI system for the test cohort was 0.74 (95% confidence interval [CI] 0.58-0.86), and 0.52 (95% CI 0.50-0.55) using the guidelines criteria (P = 0.0028). This AI model could reduce the 21% of over-surgery compared to the guidelines. CONCLUSION: We developed a pathologist-independent predictive model for LNM in T1 CRC using WSI for determination of the need for surgery after endoscopic resection. TRIAL REGISTRATION: UMIN Clinical Trials Registry (UMIN000046992, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000053590).
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Inteligência Artificial , Neoplasias Colorretais , Humanos , Metástase Linfática/patologia , Estudos Retrospectivos , Endoscopia , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/patologia , Linfonodos/patologiaRESUMO
The present study examined the therapeutic effects of preoperative neoadjuvant chemoradiation therapy (NACRT) and predictive factors for complete clinical remission, compared the prognosis and costs of abdominoperineal resection (APR) and the "watch and wait" method (WW), and evaluated the usefulness of WW. In our department, patients with stage II-III lower rectal cancer requiring APR receive NACRT. NACRT was performed as a preoperative treatment (52 Gy + S-1: 80-120 mg/day × 25 days). Eight weeks after the completion of NACRT, rectal examination, endoscopic, computed tomography, and magnetic resonance imaging findings were evaluated to assess its therapeutic effects. APR was indicated for patients in whom endoscopic findings suggested a residual tumor in which a deep ulcer or marginal swelling remained or lymph node metastasis. However, WW was selected for patients who refused APR after informed consent was obtained. In the APR and WW groups, 5- and 20-year treatment costs after CRT were calculated using the Medical Fee Points of Japan in 2020. No significant differences were observed in 3-year disease-free survival rates for either parameter between the two groups. Regarding expenses, treatment costs were lower in the WW group than in the APR group. Organ preservation using active surveillance with CRT for rectal cancer requiring APR is feasible with the achievement of endoluminal complete remission.
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OBJECTIVES: Advances in endoscopic technology, including magnifying and image-enhanced techniques, have been attracting increasing attention for the optical characterization of colorectal lesions. These techniques are being implemented into clinical practice as cost-effective and real-time approaches. Additionally, with the recent progress in endoscopic interventions, endoscopic resection is gaining acceptance as a treatment option in patients with ulcerative colitis (UC). Therefore, accurate preoperative characterization of lesions is now required. However, lesion characterization in patients with UC may be difficult because UC is often affected by inflammation, and it may be characterized by a distinct "bottom-up" growth pattern, and even expert endoscopists have relatively little experience with such cases. In this systematic review, we assessed the current status and limitations of the use of optical characterization of lesions in patients with UC. METHODS: A literature search of online databases (MEDLINE via PubMed and CENTRAL via the Cochrane Library) was performed from 1 January 2000 to 30 November 2021. RESULTS: The database search initially identified 748 unique articles. Finally, 25 studies were included in the systematic review: 23 focused on differentiation of neoplasia from non-neoplasia, one focused on differentiation of UC-associated neoplasia from sporadic neoplasia, and one focused on differentiation of low-grade dysplasia from high-grade dysplasia and cancer. CONCLUSIONS: Optical characterization of neoplasia in patients with UC, even using advanced endoscopic technology, is still challenging and several issues remain to be addressed. We believe that the information revealed in this review will encourage researchers to commit to the improvement of optical diagnostics for UC-associated lesions.
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Colite Ulcerativa , Neoplasias Colorretais , Neoplasias , Humanos , Colite Ulcerativa/diagnóstico , Colite Ulcerativa/cirurgia , Colite Ulcerativa/complicações , Colonoscopia/métodos , Hiperplasia/complicações , Tecnologia , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/etiologia , Neoplasias Colorretais/cirurgiaRESUMO
The incidence of T1 colorectal cancer is expected to increase because of the prevalence of colorectal cancer screening and the progress of endoscopic treatment such as endoscopic submucosal dissection or endoscopic full-thickness resection. Currently, the requirement for additional surgery after endoscopic resection of T1 colorectal cancer is determined according to several treatment guidelines (in USA, Europe, and Japan) referring to the following pathological findings: lymphovascular invasion, tumor differentiation, depth of invasion, and tumor budding, all of which are reported to be risk factors for lymph node metastasis. In addition to these factors, in this review, we investigate whether tumor location, which is an objective factor, has an impact on the presence of lymph node metastasis and recurrence. From recent studies, left-sided location, especially the sigmoid colon in addition to rectum, could be a risk factor for lymph node metastasis and cancer recurrence. The treatment of T1 colorectal cancer should be managed considering these findings.
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OBJECTIVES: Complete endoscopic healing, defined as Mayo endoscopic score (MES) = 0, is an optimal target in the treatment of ulcerative colitis (UC). However, some patients with MES = 0 show clinical relapse within 12 months. Histologic goblet mucin depletion has emerged as a predictor of clinical relapse in patients with MES = 0. We observed goblet depletion in vivo using an endocytoscope, and analyzed the association between goblet appearance and future prognosis in UC patients. METHODS: In this retrospective cohort study, all enrolled UC patients had MES = 0 and confirmed clinical remission between October 2016 and March 2020. We classified the patients into two groups according to the goblet appearance status: preserved-goblet and depleted-goblet groups. We followed the patients until March 2021 and evaluated the difference in cumulative clinical relapse rates between the two groups. RESULTS: We identified 125 patients with MES = 0 as the study subjects. Five patients were subsequently excluded. Thus, we analyzed the data for 120 patients, of whom 39 were classified as the preserved-goblet group and 81 as the depleted-goblet group. The patients were followed-up for a median of 549 days. During follow-up, the depleted-goblet group had a significantly higher cumulative clinical relapse rate than the preserved-goblet group (19% [15/81] vs. 5% [2/39], respectively; P = 0.02). CONCLUSIONS: Observing goblet appearance in vivo allowed us to better predict the future prognosis of UC patients with MES = 0. This approach may assist clinicians with onsite decision-making regarding treatment interventions without a biopsy.
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Colite Ulcerativa , Colite Ulcerativa/patologia , Colonoscopia , Humanos , Mucosa Intestinal/patologia , Recidiva , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
BACKGROUND AND AIMS: Recently, the use of computer-aided detection (CADe) for colonoscopy has been investigated to improve the adenoma detection rate (ADR). We aimed to assess the efficacy of a regulatory-approved CADe in a large-scale study with high numbers of patients and endoscopists. METHODS: This was a propensity score-matched prospective study that took place at a university hospital between July 2020 and December 2020. We recruited patients aged ≥20 years who were scheduled for colonoscopy. Patients with polyposis, inflammatory bowel disease, or incomplete colonoscopy were excluded. We used a regulatory-approved CADe system and conducted a propensity score matching-based comparison of the ADR between patients examined with and without CADe as the primary outcome. RESULTS: During the study period, 2261 patients underwent colonoscopy with the CADe system or routine colonoscopy, and 172 patients were excluded in accordance with the exclusion criteria. Thirty endoscopists (9 nonexperts and 21 experts) were involved in this study. Propensity score matching was conducted using 5 factors, resulting in 1836 patients included in the analysis (918 patients in each group). The ADR was significantly higher in the CADe group than in the control group (26.4% vs 19.9%, respectively; relative risk, 1.32; 95% confidence interval, 1.12-1.57); however, there was no significant increase in the advanced neoplasia detection rate (3.7% vs 2.9%, respectively). CONCLUSIONS: The use of the CADe system for colonoscopy significantly increased the ADR in a large-scale prospective study including 30 endoscopists (Clinical trial registration number: UMIN000040677.).
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Adenoma , Neoplasias Colorretais , Adenoma/diagnóstico por imagem , Inteligência Artificial , Colonoscopia , Neoplasias Colorretais/diagnóstico por imagem , Humanos , Pontuação de Propensão , Estudos ProspectivosRESUMO
OBJECTIVES: Ulcerative colitis-associated neoplasias (UCAN) are often flat with an indistinct boundary from surrounding tissues, which makes differentiating UCAN from non-neoplasias difficult. Pit pattern (PIT) has been reported as one of the most effective indicators to identify UCAN. However, regenerated mucosa is also often diagnosed as a neoplastic PIT. Endocytoscopy (EC) allows visualization of cell nuclei. The aim of this retrospective study was to demonstrate the diagnostic ability of combined EC irregularly-formed nuclei with PIT (EC-IN-PIT) diagnosis to identify UCAN. METHODS: This study involved patients with ulcerative colitis whose lesions were observed by EC. Each lesion was diagnosed by two independent expert endoscopists, using two types of diagnostic strategies: PIT alone and EC-IN-PIT. We evaluated and compared the diagnostic abilities of PIT alone and EC-IN-PIT. We also examined the difference in the diagnostic abilities of an EC-IN-PIT diagnosis according to endoscopic inflammation severity. RESULTS: We analyzed 103 lesions from 62 patients; 23 lesions were UCAN and 80 were non-neoplastic. EC-IN-PIT diagnosis had a significantly higher specificity and accuracy compared with PIT alone: 84% versus 58% (P < 0.001), and 88% versus 67% (P < 0.01), respectively. The specificity and accuracy were significantly higher for Mayo endoscopic score (MES) 0-1 than MES 2-3: 93% versus 68% (P < 0.001) and 95% versus 74% (P < 0.001), respectively. CONCLUSIONS: Our novel EC-IN-PIT strategy had a better diagnostic ability than PIT alone to predict UCAN from suspected and initially detected lesions using conventional colonoscopy. UMIN clinical trial (UMIN000040698).
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Colite Ulcerativa , Neoplasias Colorretais , Colite Ulcerativa/diagnóstico por imagem , Colonoscopia , Humanos , Projetos Piloto , Estudos RetrospectivosRESUMO
BACKGROUND AND AIMS: This study aimed to evaluate the efficacy of perioperative antibiotics against post-endoscopic submucosal dissection (ESD) coagulation syndrome (PECS) in patients undergoing colorectal ESD. METHODS: A prospective, multicenter, randomized controlled, parallel, superiority trial was conducted at 21 Japanese tertiary institutions. Patients with superficial colorectal lesions ≥20 mm and those undergoing ESD management for a single lesion were eligible. Patients with perforation during and after ESD were withdrawn. Before the ESD procedure, participants were randomly assigned (1:1) to either undergo conventional treatment (nonantibiotic group) or investigational treatment (antibiotic group). In the antibiotic group, 3 g of ampicillin-sulbactam was administered just before, 8 hours after, and the morning after ESD. The primary endpoint was the incidence of PECS. The onset of PECS was defined as localized abdominal pain (both spontaneous pain and tenderness) and fever (≥37.6°C) or inflammatory response (leukocytosis [≥10,000 cells/µL] or elevated C-reactive protein level [≥.5 mg/dL]). RESULTS: From February 5, 2019 to September 7, 2020, 432 patients were enrolled and assigned to the antibiotic group (n = 216) or nonantibiotic group (n = 216). After withdrawal of 52 patients, 192 in the antibiotic group and 188 in the nonantibiotic group were analyzed. PECS occurred in 9 of 192 patients (4.7%) in the antibiotic group and 14 of 188 patients (7.5%) in the nonantibiotic group, with an odds ratio of .61 (95% confidence interval, .23-1.56; P = .29). CONCLUSIONS: Perioperative use of antibiotics was not effective in reducing the incidence of PECS in patients undergoing colorectal ESD. (Clinical trial registration number: UMIN000035178.).
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Neoplasias Colorretais , Ressecção Endoscópica de Mucosa , Antibacterianos/uso terapêutico , Neoplasias Colorretais/cirurgia , Ressecção Endoscópica de Mucosa/efeitos adversos , Ressecção Endoscópica de Mucosa/métodos , Humanos , Estudos Prospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Although small colorectal neoplasms (< 10 mm) are often easily resected endoscopically and are considered to have less malignant potential compared with large neoplasms (≥ 10 mm), some are invasive to the submucosa. AIM: To clarify the clinicopathological features of small T1 colorectal cancers. METHODS: Of 32025 colorectal lesions between April 2001 and March 2018, a total of 1152 T1 colorectal cancers resected endoscopically or surgically were included in this study and were divided into two groups by tumor size: a small group (< 10 mm) and a large group (≥ 10 mm). We compared clinicopathological factors including lymph node metastasis (LNM) between the two groups. RESULTS: The incidence of small T1 cancers was 10.1% (116/1152). The percentage of initial endoscopic treatment in small group was significantly higher than in large group (< 10 mm 74.1% vs ≥ 10 mm 60.2%, P < 0.01). In the surgical resection cohort (n = 798), the rate of LNM did not significantly differ between the two groups (small 12.3% vs large 10.9%, P = 0.70). In addition, there were also no significant differences between the two groups in pathological factors such as histological grade, vascular invasion, or lymphatic invasion. CONCLUSION: Because there was no significant difference in the rate of LNM between small and large T1 colorectal cancers, the requirement for additional surgical resection should be determined according to pathological findings, regardless of tumor size.
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The European Society of Gastrointestinal Endoscopy does not recommend self-expanding metal stent (SEMS) placement as a bridge to surgery (BTS) for malignant colorectal obstruction (MCRO). However, no universally accepted consensus has been determined. The present study aimed to evaluate the short- and long-term outcomes of SEMS placement vs. emergency surgery (ES) for MCRO. Surgical resection of colorectal cancer was performed in 3,840 patients between April 2001 and June 2016. Of these, 93 patients had MCRO requiring emergency decompression. Only patients in whom the colorectal lesion was ultimately resected were included; thus, the present study included 62 patients treated with MCRO via SEMS placement as a BTS (n=25) or via ES (n=37). The rates of laparoscopic surgery, primary anastomosis, stoma formation, lymph node dissection, adverse events, 30-day mortality and disease-free survival were evaluated. The clinical success rate of SEMS placement was 92.0% (23/25). Compared with the ES group, the SEMS group had higher rates of laparoscopic surgery (68.0 vs. 2.7%; P<0.001) and primary anastomosis (88.0 vs. 51.4%; P=0.003), a greater number of dissected lymph nodes (30 vs. 18; P=0.001), and lower incidences of stoma formation (24.0 vs. 67.6%; P=0.002) and overall adverse events (24.0 vs. 62.2%; P=0.004). The 30-day mortality and disease-free survival of the SEMS group were not significantly different to that of the ES group (0 vs. 2.7%; P=1.000; log-rank test; P=0.10). In conclusion, as long as adverse events such as perforation are minimized, SEMS placement as a BTS could be a first treatment option for MCRO. The present study is registered in the University Hospital Medical Network Clinical Trials Registry (UMIN R000034868).
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The global incidence and mortality rate of colorectal cancer remains high. Colonoscopy is regarded as the gold standard examination for detecting and eradicating neoplastic lesions. However, there are some uncertainties in colonoscopy practice that are related to limitations in human performance. First, approximately one-fourth of colorectal neoplasms are missed on a single colonoscopy. Second, it is still difficult for non-experts to perform adequately regarding optical biopsy. Third, recording of some quality indicators (e.g. cecal intubation, bowel preparation, and withdrawal speed) which are related to adenoma detection rate, is sometimes incomplete. With recent improvements in machine learning techniques and advances in computer performance, artificial intelligence-assisted computer-aided diagnosis is being increasingly utilized by endoscopists. In particular, the emergence of deep-learning, data-driven machine learning techniques have made the development of computer-aided systems easier than that of conventional machine learning techniques, the former currently being considered the standard artificial intelligence engine of computer-aided diagnosis by colonoscopy. To date, computer-aided detection systems seem to have improved the rate of detection of neoplasms. Additionally, computer-aided characterization systems may have the potential to improve diagnostic accuracy in real-time clinical practice. Furthermore, some artificial intelligence-assisted systems that aim to improve the quality of colonoscopy have been reported. The implementation of computer-aided system clinical practice may provide additional benefits such as helping in educational poorly performing endoscopists and supporting real-time clinical decision-making. In this review, we have focused on computer-aided diagnosis during colonoscopy reported by gastroenterologists and discussed its status, limitations, and future prospects.