The prognostic value of lymph node yield in the earliest stage of colorectal cancer: a multicenter cohort study.

BACKGROUND: In patients with stage II colorectal cancer (CRC) the number of surgically retrieved lymph nodes (LNs) is associated with prognosis, resulting in a minimum of 10-12 retrieved LNs being recommended for this stage. Current guidelines do not provide a recommendation regarding LN yield in T1 CRC. Studies evaluating LN yield in T1 CRC suggest that such high LN yields are not feasible in this early stage, and a lower LN yield might be appropriate. We aimed to validate the cut-off of 10 retrieved LNs on risk for recurrent cancer and detection of LN metastasis (LNM) in T1 CRC, and explored whether this number is feasible in clinical practice. METHODS: Patients diagnosed with T1 CRC and treated with surgical resection between 2000 and 2014 in thirteen participating hospitals were selected from the Netherlands Cancer Registry. Medical records were reviewed to collect additional information. The association between LN yield and recurrence and LNM respectively were analyzed using 10 LNs as cut-off. Propensity score analysis using inverse probability weighting (IPW) was performed to adjust for clinical and histological confounding factors (i.e., age, sex, tumor location, size and morphology, presence of LNM, lymphovascular invasion, depth of submucosal invasion, and grade of differentiation). RESULTS: In total, 1017 patients with a median follow-up time of 49.0 months (IQR 19.6-81.5) were included. Four-hundred five patients (39.8%) had a LN yield ≥ 10. Forty-one patients (4.0%) developed recurrence. LN yield ≥ 10 was independently associated with a decreased risk for recurrence (IPW-adjusted HR 0.20; 95% CI 0.06-0.67; P = 0.009). LNM were detected in 84 patients (8.3%). LN yield ≥ 10 was independently associated with increased detection of LNM (IPW-adjusted OR 2.27; 95% CI 1.39-3.69; P = 0.001). CONCLUSIONS: In this retrospective observational study, retrieving < 10 LNs was associated with an increased risk of CRC recurrence, advocating the importance to perform an appropriate oncologic resection of the draining LNs and diligent LN search when patients with T1 CRC at high-risk for LNM are referred for surgical resection. Given that both gastroenterologists, surgeons and pathologists will encounter T1 CRCs with increasing frequency due to the introduction of national screening programs, awareness on the consequences of an inadequate LN retrieval is of utmost importance.

Colonoscopy with robotic steering and automated lumen centralization: a feasibility study in a colon model.

BACKGROUND AND STUDY AIMS: We introduced a new platform for performing colonoscopy with robotic steering and automated lumen centralization (RS-ALC) and evaluated its technical feasibility. PARTICIPANTS AND METHODS: Expert endoscopists (n = 8) and endoscopy-naive novices (n = 10) used conventional steering and RS-ALC to perform colonoscopy in a validated colon model with simulated polyps (n = 21). The participants were randomized to which modality they were to use first. End points were the cecal intubation time, number of detected polyps, and subjective evaluation of the platform. RESULTS: Novices were able to intubate the cecum faster with RS-ALC (median 8 minutes [min] 56 seconds [s], interquartile range [IQR] 6  min 46  s - 16  min 34  s vs. median 11  min 47  s, IQR 8  min 19  s - 15  min 33  s, P = 0.65), whereas experts were faster with conventional steering (median 2  min 9  s, IQR 1  min 13 s - 7  min 28  s vs. median 13  min 1  s, IQR 5  min 9 s - 16  min 54  s, P = 0.12). Novices detected more polyps with RS-ALC (median 88.1 %, IQR 79.8 % - 95.2 % vs. median 78.6 %, IQR 75.0 % - 91.7 %, P = 0.17), whereas experts detected more polyps with conventional steering (median 80.9 %, IQR 76.2 % - 85.7 % vs. median 69.0 %, IQR 61.0 % - 75.0 %, P = 0.03). Novices were more positive than experts about the new platform (P = 0.02), noting an easier and faster introduction of the colonoscope with RS-ALC than with conventional steering. CONCLUSIONS: Colonoscopy with RS-ALC is technically feasible and appears to be easier and more intuitive than conventional steering for endoscopy-naive novices.

No decrease in the rate of early or missed colorectal cancers after colonoscopy with polypectomy over a 10-year period: a population-based analysis.

BACKGROUND & AIMS: It is not clear whether the incidence of missed or early colorectal cancers (CRCs) has decreased over time. We compared the rates of missed or early CRC after polypectomy between 1996 and 2006, and aimed to identify risk factors for these. METHODS: We performed a population-based, case-control study linking data from the Dutch Pathology Registry with data from The Netherlands Cancer Registry. Of all patients with an incident CRC in 1996 and 2006, we identified whether colonic histology specimens were available in the preceding 3 years. Patients with early or missed CRC were defined as those with previous colonic histology in the 6 to 36 months preceding CRC diagnosis. We performed multivariate logistic regression analysis to identify factors associated with missed or early CRCs. RESULTS: CRC was diagnosed in 6941 patients in 1996 and in 10,963 patients in 2006. The proportion of patients with early or missed CRC was 1.7% of all CRC patients in 1996 and 2.3% in 2006 (P = .012). Early or missed CRCs had a lower tumor, nodal, and metastasis stage than regularly diagnosed CRCs (P < .001), but rate of survival, adjusted for TNM stage, did not differ. CRCs of the right colon and transverse colon and splenic flexure were associated with a missed or early CRC (odds ratio [OR], 2.34; 95% confidence interval [CI], 1.80-3.05; and OR, 2.14; 95% CI, 1.49-3.08, respectively), as was male sex (OR, 1.31; 95% CI, 1.06-1.62). CONCLUSIONS: Based on an analysis of the Dutch population, there has been no decrease in the occurrence of missed or early CRCs over a 10-year period. Location in the right side of the colon was an independent risk factor for missed or early CRCs.

Open-access flexible sigmoidoscopy frequently leads to additional colonoscopy in symptomatic patients over 50 years.

BACKGROUND & AIMS: General practitioners (GPs) in the Netherlands have open access to flexible sigmoidoscopy (FS) for patients with lower gastrointestinal symptoms, but not to colonoscopy. This study was performed to investigate the yield of FS in GP-referred patients, to evaluate the proportion of patients in whom additional colonoscopy was performed and to investigate whether there was a subgroup of patients referred for symptoms with a low risk of detecting significant findings. METHODS: All patients undergoing FS in 2008 and 2009 who were referred by GPs were analyzed. Indications for additional colonoscopy were the presence of polyps and/or colorectal cancer (CRC), polyp screening or surveillance, incomplete FS or other reasons. RESULTS: In total, 916 patients underwent FS. A cause for the symptoms was found in 44.2% of patients. In patients aged 50 years or older, additional colonoscopy was more frequently performed than in younger patients (27.5% vs. 9.6%, OR=3.6 [95% CI 2.4-5.4]), mainly due to a higher prevalence of adenomatous polyps (29.9% vs. 10.5%, OR=3.6 [95% CI 2.4-5.4]) and CRC (7.5% vs. 1.3%, OR=6.2 [95% CI 2.2-17.5]) during FS. In 7.8% patients undergoing FS for abdominal pain as the presenting symptom, a probable cause for the symptoms was found, mainly diverticular disease. CONCLUSION: Due to the high prevalence of polyps and CRC in symptomatic patients aged 50 years or older undergoing FS, an additional colonoscopy is performed frequently. In patients referred with abdominal pain, FS is unlikely to reveal a relevant cause for the symptoms.

Symptoms associated with finding colorectal cancer during colonoscopy.

BACKGROUND: Patients with an increased risk of having colorectal cancer (CRC) should have priority on the colonoscopy list. OBJECTIVE: To investigate whether presenting symptoms of patients referred for colonoscopy could help in identifying patients with an increased risk of CRC. PATIENTS AND METHODS: Between February 2007 and November 2010, random outpatients referred for colonoscopy were asked to fill out a questionnaire with respect to symptoms for which the colonoscopy was performed. Informed consent was obtained to review the colonoscopy and histology reports. Multivariate logistic regression was performed to identify predictors for CRC. RESULTS: In total, 1458 (21%) patients returned the questionnaire, of whom 925 (63.4%) had undergone previous sigmoidoscopy or colonoscopy. CRC was detected in 41 patients (2.8%). Age over 50 years [adjusted odds ratio (aOR) 3.00; 95% confidence interval (CI) 1.30-6.91] and presenting symptoms of rectal blood loss (aOR 4.62; 95% CI 2.31-9.22) and a change in bowel habits (aOR 3.33; 95% CI 1.50-7.40) were associated independently with an increased risk of finding CRC. Previous sigmoidoscopy or colonoscopy (aOR 0.24; 95% CI 0.12-0.49) and fatigue as presenting symptoms (aOR 0.22; 95% CI 0.09-0.56) were associated with a decreased risk of CRC. Weight loss, self-reported anemia, and abdominal pain were not associated with CRC in this study. CONCLUSION: Patients presenting with rectal blood loss, change in bowel habits, and those older than 50 years of age have an increased risk of a finding of CRC during colonoscopy. We recommend that these risk groups should be prioritized on the colonoscopy list over patients who have undergone a previous endoscopy or who are presenting with fatigue.

CT-colonography after incomplete colonoscopy: what is the diagnostic yield?

BACKGROUND: Computed tomography-colonography is a diagnostic modality that can be used when the colon is not completely intubated during colonoscopy. It may have the additional advantage that information on extracolonic lesions can be obtained. OBJECTIVE: The aim of this study was to investigate the yield of CT-colonography of relevant intra- and extracolonic findings in patients after incomplete colonoscopy. DESIGN: This was an observational, retrospective study. DATA SOURCES: Data were be obtained from standardized radiology and endoscopy reports and electronic medical records. STUDY SELECTION: In total, 136 consecutive CT-colonographies performed after incomplete colonoscopy were evaluated. MAIN OUTCOME MEASURES: All intra- and extracolonic findings on CT-colonography were recorded and interpreted for clinical relevance, and it was determined whether further diagnostic and/or therapeutic workup was indicated. RESULTS: Major indications for colonoscopy included iron-deficiency anemia (25.7%), hematochezia (20.6%), change in bowel habits (18.4%), and colorectal cancer screening or surveillance (11.0%). Major reasons for incomplete colonoscopy were a fixed colon (34.6%) and strong angulation of the sigmoid colon (17.6%). Introduction of the colonoscope was limited to the left-sided colon in 53.7% of cases. Incomplete colonoscopy detected colorectal cancer in 12 (8.8%) patients and adenomatous polyps in 27 (19.9%) patients. CT-colonography after incomplete colonoscopy additionally revealed 19 polyps in 15 (11.0%) and a nonsynchronous colorectal cancer in 4 (2.9%) patients. CT-colonography also detected extracolonic findings with clinical consequences in 8 (5.9%) patients, including fistulizing diverticulitis (n = 3), gastric tumor (n = 2), liver abscess (n = 1), osteomyelitis (n = 1), and an infected embolus in both renal arteries (n = 1). LIMITATIONS: This study was limited by the lack of confirmation of intraluminal CT-colonography findings in a subset of patients. CONCLUSIONS: Computed tomography-colonography can be of added value in patients with incomplete colonoscopy, because it revealed 27 relevant additional (both intra- and extracolonic) lesions in 19.1% of patients. In cases where CT-colonography detected colorectal cancer after incomplete colonoscopy, it can also be used for staging purposes.

Endoscopic clip-assisted feeding tube placement reduces repeat endoscopy rate: results from a randomized controlled trial.

OBJECTIVES: To determine whether endoscopic clip-assisted nasoenteral feeding tube placement is more effective than standard feeding tube placement with transnasal endoscopy. METHODS: Between August 2009 and February 2011, 143 patients referred for endoscopic nasoenteral feeding tube placement were randomized between clip-assisted and standard nasoenteral tube placement. Endoscopies were performed in the endoscopy unit and intensive care unit in a tertiary referral center in the Netherlands. For the clip-assisted procedure, the feeding tube was introduced with a suture fixed to the tip, picked up in the stomach with an endoclip and attached (as distal as possible) to the duodenal wall. In the standard group, a guide wire was placed in the duodenum using a transnasal endoscope, followed by blind insertion of a feeding tube over the guide wire. Primary end point was a repeat endoscopy for incorrect tube placement or spontaneous retrograde tube migration. Secondary end points were incorrect tube placement, spontaneous migration of feeding tube, directs medical costs, and procedure-related (serious) adverse event (SAE). RESULTS: Of the 143 patients included, 71 were randomly assigned to clip-assisted tube placement, and 72 to standard tube placement. Four (5.6%) repeat endoscopies were performed in the clip-assisted group vs. 19 (26.4%) in the standard group (relative risk reduction (RRR) 0.79; 95% confidence interval (CI) 0.40-0.92). The number needed to clip to avoid one repeat endoscopy was 4.8 (95% CI 3.1-11.3). Repeat endoscopies were mostly performed for incorrectly placed tubes, 3 (4.2%) in the clip-assisted group vs. 16 (22.2%, RRR 0.81; 95% CI 0.38-0.94) in the standard group. Spontaneous retrograde tube migration occurred in one (1.4%) clip-assisted placement and three (4.2%) standard tubes. Median costs were higher for clip-assisted tube placement (€519 vs. €423, P<0.01). Four (5.6%) SAEs occurred after clip-assisted feeding tube placement vs. one (1.4%) after standard feeding tube placement (P=0.21). CONCLUSIONS: Clip-assisted endoscopic nasoenteral feeding tube placement results in fewer repeat endoscopies than standard endoscopic nasoenteral tube placement, due to a higher success rate of initial placement. When tubes are adequately placed, retrograde tube migration rarely occurs.