RESUMEN
BACKGROUND & AIMS: Follow-up (FU) strategies after endoscopic eradication therapy (EET) for Barrett's neoplasia do not consider the risk of mortality from causes other than esophageal adenocarcinoma (EAC). We aimed to evaluate this risk during long-term FU, and to assess whether the Charlson Comorbidity Index (CCI) can predict mortality. METHODS: We included all patients with successful EET from the nationwide Barrett registry in the Netherlands. Data were merged with National Statistics for accurate mortality data. We evaluated annual mortality rates (AMRs, per 1000 person-years) and standardized mortality ratio for other-cause mortality. Performance of the CCI was evaluated by discrimination and calibration. RESULTS: We included 1154 patients with a mean age of 64 years (±9). During median 59 months (p25-p75 37-91; total 6375 person-years), 154 patients (13%) died from other causes than EAC (AMR, 24.1; 95% CI, 20.5-28.2), most commonly non-EAC cancers (n = 58), cardiovascular (n = 31), or pulmonary diseases (n = 26). Four patients died from recurrent EAC (AMR, 0.5; 95% CI, 0.1-1.4). Compared with the general Dutch population, mortality was significantly increased for patients in the lowest 3 age quartiles (ie, age <71 years). Validation of CCI in our population showed good discrimination (Concordance statistic, 0.78; 95% CI, 0.72-0.84) and fair calibration. CONCLUSION: The other-cause mortality risk after successful EET was more than 40 times higher (48; 95% CI, 15-99) than the risk of EAC-related mortality. Our findings reveal that younger post-EET patients exhibit a significantly reduced life expectancy when compared with the general population. Furthermore, they emphasize the strong predictive ability of CCI for long-term mortality after EET. This straightforward scoring system can inform decisions regarding personalized FU, including appropriate cessation timing. (NL7039).
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Adenocarcinoma , Esófago de Barrett , Neoplasias Esofágicas , Sistema de Registros , Humanos , Persona de Mediana Edad , Masculino , Esófago de Barrett/cirugía , Esófago de Barrett/mortalidad , Esófago de Barrett/patología , Femenino , Países Bajos/epidemiología , Anciano , Neoplasias Esofágicas/mortalidad , Neoplasias Esofágicas/cirugía , Incidencia , Adenocarcinoma/mortalidad , Adenocarcinoma/cirugía , Adenocarcinoma/patología , Esofagoscopía/efectos adversos , Causas de Muerte , Medición de Riesgo , Factores de Riesgo , Resultado del Tratamiento , Factores de Tiempo , ComorbilidadRESUMEN
BACKGROUND & AIMS: Although random histological sampling from the esophagogastric junction (EGJ) after complete eradication of Barrett's esophagus (BE) is recommended, its clinical relevance is questionable. This study aimed to assess the incidence and long-term outcomes of findings from random EGJ biopsies in a nationwide cohort with long-term follow-up. METHODS: We included all patients with successful endoscopic eradication therapy (EET), defined as complete endoscopic eradication of all visible BE (CE-BE), for early BE neoplasia from the Dutch registry. Patients were treated and followed-up in 9 expert centers according to a joint protocol. Outcomes included the incidence of intestinal metaplasia (IM) at the EGJ (EGJ-IM) and the association between IM and visible (dysplastic) BE recurrence. RESULTS: A total of 1154 patients were included with a median follow-up of 43 months (interquartile range, 22-69 months). At the time of CE-BE, persisting EGJ-IM was found in 7% of patients (78/1154), which was reproduced during further follow-up in 46% of patients (42/78). No significant association existed between persisting EGJ-IM at CE-BE and recurrent non-dysplastic or dysplastic BE (hazard ratio [HR], 1.15; 95% confidence interval [CI], 0.63-2.13 and HR, 0.73; 95% CI, 0.17-3.06, respectively). Among patients with no EGJ-IM at the time of CE-BE (1043/1154; 90%), EGJ-IM recurred in 7% (72/1043) after a median of 21 months (interquartile range, 15-36 months), and was reproduced during further follow-up in 26% of patients (19/72). No association was found between recurrent EGJ-IM and non-dysplastic or dysplastic recurrence (HR, 1.18; 95% CI, 0.67-2.06 and HR, 0.27; 95% CI, 0.04-1.96, respectively). CONCLUSION: Because EGJ-IM was not associated with a higher risk for recurrent disease, we recommend to consider abandoning random EGJ sampling after successful EET, under the condition that care is provided in expert centers, and the esophagus, including the EGJ, is carefully inspected (Netherlands Trial Register, NL7309).
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Esófago de Barrett , Ablación por Catéter , Neoplasias Esofágicas , Humanos , Esófago de Barrett/cirugía , Esófago de Barrett/patología , Relevancia Clínica , Recurrencia Local de Neoplasia/epidemiología , Unión Esofagogástrica/patología , Biopsia , Metaplasia/patología , Esofagoscopía , Neoplasias Esofágicas/patología , Resultado del TratamientoRESUMEN
BACKGROUND AND AIMS: After endoscopic resection (ER) of early esophageal adenocarcinoma (EAC), the optimal management of patients with high-risk histologic features for lymph node metastases (ie, submucosal invasion, poor differentiation grade, or lymphovascular invasion) remains unclear. We aimed to evaluate outcomes of endoscopic follow-up after ER for high-risk EAC. METHODS: For this retrospective cohort study, data were collected from all Dutch patients managed with endoscopic follow-up (endoscopy, EUS) after ER for high-risk EAC between 2008 and 2019. We distinguished 3 groups: intramucosal cancers with high-risk features, submucosal cancers with low-risk features, and submucosal cancers with high-risk features. The primary outcome was the annual risk for metastases during follow-up, stratified for baseline histology. RESULTS: One hundred twenty patients met the selection criteria. Median follow-up was 29 months (interquartile range, 15-48). Metastases were observed in 5 of 25 (annual risk, 6.9%; 95% confidence interval [CI], 3.0-15) high-risk intramucosal cancers, 1 of 55 (annual risk, .7%; 95% CI, 0-4.0) low-risk submucosal cancers, and 3 of 40 (annual risk, 3.0%; 95% CI, 0-7.0) high-risk submucosal cancers. CONCLUSIONS: Whereas the annual metastasis rate for high-risk submucosal EAC (3.0%) was somewhat lower than expected in comparison with previous reported percentages, the annual metastasis rate of 6.9% for high-risk intramucosal EAC is new and worrisome. This calls for further prospective studies and suggests that strict follow-up of this small subgroup is warranted until prospective data are available.
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Adenocarcinoma , Neoplasias Esofágicas , Adenocarcinoma/patología , Endoscopía , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/cirugía , Estudios de Seguimiento , Humanos , Invasividad Neoplásica , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
BACKGROUND : Clinical tumor stage of esophageal adenocarcinoma (EAC) is determined by endoscopic ultrasound and/or computed tomography scan, which have low accuracy for stages T1 and T2, potentially leading to overtreatment. We aimed to assess the proportion of cT2 EACs downstaged to cT1 after endoscopic reassessment (ERA) by an experienced interventional endoscopist. METHODS : We performed a prospective multicenter cohort study. Patients with cT2N0M0 EAC were included and underwent ERA. The primary outcome was proportion of cT2 EACs downstaged to cT1 after ERA. RESULTS : 15/25 included patients (60â%) were downstaged from cT2 to cT1 EAC after ERA and underwent attempted endoscopic resection. Endoscopic resection was aborted in 3/15 patients because of tumor invasion into the muscle layer; all three underwent successful surgical resection. Endoscopic resection was successful in 12/15 patients (80â%), all of whom had pT1 tumors. Overall, 10/25 (40â%) were treated with endoscopic resection alone. CONCLUSIONS : ERA downstaged about half of the cT2 tumors to cT1, rendering them suitable for endoscopic resection. ERA had substantial clinical impact on therapeutic management, preventing overtreatment in 40â% of patients.
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Adenocarcinoma , Neoplasias Esofágicas , Adenocarcinoma/diagnóstico por imagen , Adenocarcinoma/patología , Adenocarcinoma/cirugía , Estudios de Cohortes , Endosonografía , Neoplasias Esofágicas/diagnóstico por imagen , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/cirugía , Esofagectomía/métodos , Humanos , Estadificación de Neoplasias , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
BACKGROUND : The optimal management for patients with low grade dysplasia (LGD) in Barrett's esophagus (BE) is unclear. According to the Dutch national guideline, all patients with LGD with histological confirmation of the diagnosis by an expert pathologist (i.âe. "confirmed LGD"), are referred for a dedicated re-staging endoscopy at an expert center. We aimed to assess the diagnostic value of re-staging endoscopy by an expert endoscopist for patients with confirmed LGD. METHODS : This retrospective cohort study included all patients with flat BE diagnosed in a community hospital who had confirmed LGD and were referred to one of the nine Barrett Expert Centers (BECs) in the Netherlands. The primary outcome was the proportion of patients with prevalent high grade dysplasia (HGD) or cancer during re-staging in a BEC. RESULTS : Of the 248 patients with confirmed LGD, re-staging in the BEC revealed HGD or cancer in 23â% (57/248). In 79â% (45/57), HGD or cancer in a newly detected visible lesion was diagnosed. Of the remaining patients, re-staging in the BEC showed a second diagnosis of confirmed LGD in 68â% (168/248), while the remaining 9â% (23/248) had nondysplastic BE. CONCLUSION : One quarter of patients with apparent flat BE with confirmed LGD diagnosed in a community hospital had prevalent HGD or cancer after re-staging at an expert center. This endorses the advice to refer patients with confirmed LGD, including in the absence of visible lesions, to an expert center for re-staging endoscopy.
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Adenocarcinoma , Esófago de Barrett , Neoplasias Esofágicas , Lesiones Precancerosas , Adenocarcinoma/diagnóstico por imagen , Adenocarcinoma/patología , Esófago de Barrett/diagnóstico , Esófago de Barrett/patología , Progresión de la Enfermedad , Endoscopía Gastrointestinal , Neoplasias Esofágicas/diagnóstico por imagen , Neoplasias Esofágicas/patología , Hospitales Comunitarios , Humanos , Hiperplasia , Lesiones Precancerosas/diagnóstico , Lesiones Precancerosas/patología , Estudios RetrospectivosRESUMEN
BACKGROUND: The use of endoscopic submucosal dissection (ESD) is gradually expanding for treatment of neoplasia in Barrett's esophagus (BE). We aimed to report outcomes of all ESDs for BE neoplasia performed in the Netherlands. METHODS: Retrospective assessment of outcomes, using treatment and follow-up data from a joint database. RESULTS: 130/138 patients had complete ESDs, with 126/130 (97â%) en bloc resections. Median (interquartile range (IQR)) procedure time was 121 minutes (90-180). Pathology findings were high grade dysplasia (HGD) (5â%) or esophageal adenocarcinoma (EAC) T1a (43â%) or T1b (52â%; 19â% sm1, 33â%â≥âsm2). Among resections of HGD or T1a EAC lesions, 87â% (95â%CI 75â%-92â%) were both en bloc and R0; the corresponding value for T1b EAC lesions was 49â% (36â%-60â%). Among R1 resections, 10/34 (29â%) showed residual cancer, all detected at first endoscopic follow-up.âThe remaining 24 patients (71â%) showed no residual neoplasia. Six of these patients underwent surgery with no residual tumor; the remaining 18 underwent endoscopic follow-up during median 31 months with 1 local recurrence (annual recurrence rate 2â%). Among R0 resections, annual local recurrence rate during median 27 months was 0.5â%. CONCLUSION: In expert hands, ESD allows safe removal of bulky intraluminal neoplasia and submucosal cancer. ESD of the latter showed R1 resection margins in 50â%, yet only one third had persisting neoplasia at follow-up.âTo better stratify R1 patients with an indication for additional surgery, repeat endoscopy after healing of the ESD might be a helpful possible prognostic factor for residual cancer.
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Esófago de Barrett , Resección Endoscópica de la Mucosa , Neoplasias Esofágicas , Adenocarcinoma , Esófago de Barrett/patología , Esófago de Barrett/cirugía , Resección Endoscópica de la Mucosa/métodos , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/cirugía , Humanos , Neoplasia Residual , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Endoscopic eradication therapy with radiofrequency ablation (RFA) is effective in most patients with Barrett's esophagus (BE). However, some patients experience poor healing and/or poor squamous regeneration. We evaluated incidence and treatment outcomes of poor healing and poor squamous regeneration. METHODS: We included all patients treated with RFA for early BE neoplasia from a nationwide Dutch registry based on a joint treatment protocol. Poor healing (active inflammatory changes or visible ulcerations ≥â3 months post-RFA), poor squamous regeneration (<â50â% squamous regeneration), and treatment success (complete eradication of BE [CE-BE]) were evaluated. RESULTS: 1386 patients (median BE C2M5) underwent RFA with baseline low grade dysplasia (27â%), high grade dysplasia (30â%), or early cancer (43â%). In 134 patients with poor healing (10â%), additional time and acid suppression resulted in complete esophageal healing, and 67/134 (50â%) had normal squamous regeneration with 97â% CE-BE. Overall, 74 patients had poor squamous regeneration (5â%). Compared with patients with normal regeneration, patients with poor squamous regeneration had a higher risk for treatment failure (64â% vs. 2â%, relative risk [RR] 27 [95â% confidence interval [CI] 18-40]) and progression to advanced disease (15â% vs.â<â1â%, RR 30 [95â%CI 12-81]). Higher body mass index, longer BE segment, reflux esophagitis, andâ<â50â% squamous regeneration after baseline endoscopic resection were independently associated with poor squamous regeneration in multivariable logistic regression. CONCLUSIONS: In half of the patients with poor healing, additional time and acid suppression led to normal squamous regeneration and excellent treatment outcomes. In patients with poor squamous regeneration, however, the risk for treatment failure and progression to advanced disease was significantly increased.
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Esófago de Barrett , Carcinoma de Células Escamosas , Ablación por Catéter , Neoplasias Esofágicas , Esófago de Barrett/cirugía , Carcinoma de Células Escamosas/cirugía , Ablación por Catéter/métodos , Neoplasias Esofágicas/etiología , Neoplasias Esofágicas/cirugía , Esofagoscopía/métodos , Humanos , Incidencia , Regeneración , Resultado del TratamientoRESUMEN
BACKGROUND: Lymph node metastasis (LNM) is possible after endoscopic resection of early esophageal adenocarcinoma (EAC). This study aimed to develop and internally validate a prediction model that estimates the individual risk of metastases in patients with pT1b EAC. METHODS: A nationwide, retrospective, multicenter cohort study was conducted in patients with pT1b EAC treated with endoscopic resection and/or surgery between 1989 and 2016. The primary end point was presence of LNM in surgical resection specimens or detection of metastases during follow-up.âAll resection specimens were histologically reassessed by specialist gastrointestinal pathologists. Subdistribution hazard regression analysis was used to develop the prediction model. The discriminative ability of this model was assessed using the c-statistic. RESULTS: 248 patients with pT1b EAC were included. Metastases were seen in 78 patients, and the 5-year cumulative incidence was 30.9â% (95â% confidence interval [CI] 25.1â%-36.8â%). The risk of metastases increased with submucosal invasion depth (subdistribution hazard ratio [SHR] 1.08, 95â%CI 1.02-1.14, for every increase of 500 µm), lymphovascular invasion (SHR 2.95, 95â%CI 1.95-4.45), and for larger tumors (SHR 1.23, 95â%CI 1.10-1.37, for every increase of 10âmm). The model demonstrated good discriminative ability (c-statistic 0.81, 95â%CI 0.75-0.86). CONCLUSIONS: A third of patients with pT1b EAC experienced metastases within 5 years. The probability of developing post-resection metastases was estimated with a personalized predicted risk score incorporating tumor invasion depth, tumor size, and lymphovascular invasion. This model requires external validation before implementation into clinical practice.
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Adenocarcinoma , Neoplasias Esofágicas , Adenocarcinoma/patología , Adenocarcinoma/cirugía , Estudios de Cohortes , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/cirugía , Humanos , Ganglios Linfáticos/patología , Metástasis Linfática/patología , Invasividad Neoplásica/patología , Estadificación de Neoplasias , Estudios RetrospectivosRESUMEN
BACKGROUND AND AIMS: Endoscopic resection is often feasible for submucosal invasive colorectal cancers (T1 CRCs) and usually judged as complete. If histology casts doubt on the radicality of resection margins, adjuvant surgical resection is advised, although residual intramural cancer is found in only 5% to 15% of patients. We assessed the sensitivity of biopsy specimens from the resection area for residual intramural cancer as a potential tool to estimate the preoperative risk of residual intramural cancer in patients without risk factors for lymph node metastasis (LNM). METHODS: In this multicenter prospective cohort study, patients with complete endoscopic resection of T1 CRC, scheduled for adjuvant resection due to pathologically unclear resection margins, but absent risk factors for LNM, were asked to consent to second-look endoscopy with biopsies. The results were compared with the pathology results of the surgical resection specimen (criterion standard). RESULTS: One hundred three patients were included. In total, 85% of resected lesions were unexpectedly malignant, and 45% were removed using a piecemeal resection technique. Sixty-four adjuvant surgical resections and 39 local full-thickness resections were performed. Residual intramural cancer was found in 7 patients (6.8%). Two of these patients had cancer in second-look biopsy specimens, resulting in a sensitivity of 28% (95% confidence interval, <58%). The preoperative risk of residual intramural cancer in the case of negative biopsy specimens was not significantly reduced (P = .61). CONCLUSIONS: The sensitivity of second-look endoscopy with biopsies for residual intramural cancer after endoscopic resection of CRC is low. Therefore, it should not be used in the decision whether or not to perform adjuvant resection. (Clinical trial registration number: NCT02328664.).
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Neoplasias Colorrectales , Colonoscopía , Neoplasias Colorrectales/cirugía , Humanos , Neoplasia Residual/diagnóstico , Estudios ProspectivosRESUMEN
BACKGROUND: Covered esophageal self-expandable metal stents (SEMSs) are currently used for palliation of malignant dysphagia. The optimal extent of the covering to prevent recurrent obstruction is unknown. Therefore, we aimed to compare fully covered (FC) versus partially covered (PC) SEMSs in patients with incurable malignant esophageal stenosis. METHODS: In this multicenter randomized controlled trial, 98 incurable patients with dysphagia caused by a malignant stricture of the esophagus or cardia were randomized 1:1 to an FC-SEMS or PC-SEMS.âThe primary outcome was recurrent obstruction after endoscopic SEMS placement. Secondary outcomes were technical and clinical success, adverse events, and health-related quality of life (HRQoL). Patients were followed until 6 months after SEMS placement or to SEMS removal, second SEMS insertion, or death, whichever came first. RESULTS: Recurrent obstruction after SEMS placement was similar for both types of stents: 19â% for FC-SEMSs and 22â% for PC-SEMSs (Pâ=â0.65). The times to recurrent obstruction did not differ. The frequency of adverse events was similar between the two groups, with major adverse events occurring in 38â% and 47â% of patients for FC-SEMSs and PC-SEMSs, respectively (Pâ=â0.34). No significant differences were seen in technical success, improvement of dysphagia, and HRQoL. Proximal esophageal stenosis and female sex were independently associated with recurrent obstruction and/or major adverse events. CONCLUSIONS: Esophageal FC-SEMSs did not reveal a lower recurrent obstruction rate compared with PC-SEMSs in the palliative management of malignant dysphagia.
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Trastornos de Deglución/terapia , Neoplasias Esofágicas/complicaciones , Estenosis Esofágica/terapia , Stents Metálicos Autoexpandibles , Anciano , Anciano de 80 o más Años , Trastornos de Deglución/etiología , Endoscopía Gastrointestinal , Estenosis Esofágica/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cuidados Paliativos , Falla de Prótesis , Calidad de Vida , Recurrencia , Stents Metálicos Autoexpandibles/efectos adversos , Resultado del TratamientoRESUMEN
Background and study aims Treatment strategies for clinical (c)T2N0M0 esophageal adenocarcinoma (EAC) are subject to debate owing to the relative inaccuracy of tumor staging by endoscopic ultrasound (EUS), with profound implications in overstaged patients. We aimed to evaluate the final histological diagnosis of patients initially staged as having a cT2 tumor by EUS, and to assess the value of endoscopic reassessment by an interventional endoscopist, followed by an endoscopic resection when deemed feasible. Patients and methods Two distinct cohorts of patients with cT2 EAC as determined by EUS were included: a retrospective surgical cohort of patients treated by primary esophagectomy, and a prospective cohort of patients who underwent an endoscopic reassessment by an interventional endoscopist. The main outcome measure was the final pathological (p)T stage. Results We identified 134 patients with stage T2 EAC from the surgical cohort. In 72 patients treated by primary esophagectomy, 32/72 (44â%) were downstaged to a pT1 tumor. In 12/72 (17â%), the surgical resection specimen showed tumor characteristics that fulfilled the current criteria for a curative endoscopic resection. In 13 prospectively identified patients with cT2N0M0 EAC, an expert endoscopic reassessment was done. In 11/13 (85â%) the lesion appeared endoscopically resectable and a complete endoscopic resection was performed. Histology revealed a pT1 tumor in all 11 patients, with 5/13 (38â%) fulfilling current criteria for a curative endoscopic resection. Conclusions In this study, 44â% of cT2 EACs were in fact pT1 tumors. Curative treatment by endoscopic resection was achieved in more than a third of these cases. To avoid an unnecessary esophagectomy, an endoscopic reassessment by an interventional endoscopist is recommended for all patients with cT2N0M0 EAC.
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Adenocarcinoma/patología , Adenocarcinoma/cirugía , Resección Endoscópica de la Mucosa , Endosonografía , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/cirugía , Adenocarcinoma/diagnóstico por imagen , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias Esofágicas/diagnóstico por imagen , Esofagectomía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Estudios Retrospectivos , Carga Tumoral , Procedimientos InnecesariosRESUMEN
BACKGROUND AND STUDY AIMS: Cecal intubation rate (CIR) and adenoma detection rate (ADR) have been found to be inversely associated with the occurrence of post-colonoscopy colorectal cancer. Depicting differences in CIR and ADR between hospitals could provide incentives for quality improvement. The aim of this study was to compare quality parameters of routine colonoscopies between seven hospitals in The Netherlands in order to determine the extent to which possible differences were attributable to procedural and institutional factors. PATIENTS AND METHODS: Consecutive patients undergoing colonoscopy were prospectively included between November 2012 and January 2013âat two academic and five nonacademic hospitals. Patients with inflammatory bowel disease or hereditary colorectal cancer syndromes were excluded. Main outcome measures were CIR and ADR. RESULTS: A total of 3129 patients were included (mean age 59â±â15 years; 45.5â% male). The majority of patients (86.2â%) had a Boston Bowel Preparation Scale (BBPS) score ≥ 6. Overall CIR was 94.8â%, ranging from 89.4â% to 99.2â% between hospitals. After adjustment for case mix (age, sex, American Society of Anesthesiologists score, and indication for colonoscopy), factors associated with CIR were hospital and a BBPS score ≥ 6.âOverall ADR was 31.8â% and varied between hospitals, ranging from 24.8â% to 46.8â%. Independent predictors for ADR were hospital, BBPS score ≥ 6, and cecal intubation. By combining CIR and ADR for each hospital, a colonoscopy quality indicator (CQI) was developed, which can be used by hospitals to stimulate quality improvement. CONCLUSION: Differences in the quality of colonoscopy between hospitals can be demonstrated using CIR and ADR. As both indicators are affected by institution and bowel preparation, a comparison between hospitals based on the newly developed CQI could assist in further improving the quality of colonoscopy.
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Adenoma/diagnóstico , Ciego , Competencia Clínica , Colonoscopía/normas , Neoplasias Colorrectales/diagnóstico , Hospitales/estadística & datos numéricos , Intubación/normas , Tamizaje Masivo/métodos , Mejoramiento de la Calidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND & AIMS: The efficacy of colorectal cancer screening programs depends on the rate of attendance at surveillance colonoscopy examinations. Increasing patients' awareness about the importance of surveillance might improve attendance, but it is not clear how much they know about their follow-up recommendations. We assessed the awareness of patients with adenomas about their surveillance recommendations. METHODS: Ten endoscopy departments provided access to their colonoscopy database for quality assurance; 2 datasets were obtained. We analyzed data from 4000 colonoscopies (400 per department) performed on patients with adenomas. All the patients were mailed a survey to determine how much information they had about their colonoscopy results and their follow-up recommendations. Data from 549 patients were included in the analysis. We also assessed surveillance attendance among 500 patients (50 per department) who had adenomas removed. RESULTS: Of the patients analyzed, 85% recalled retrieval of polyps during their colonoscopy, and 85% recalled whether they needed surveillance or not. The indication for surveillance was recalled by 69% of patients (range between departments, 55%-83%; P < .01). Factors that were associated with awareness of recommendations were younger age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.06-1.09), treatment by a gastroenterologist (OR, 5.53; 95% CI, 3.28-9.32), and presence of 3 or more adenomas (OR, 2.97; 95% CI, 1.29-6.85). Attendance among patients with adenomas varied among departments, from 60% to 89% (P < .01), and was not associated with awareness of patients about their recommendations per department (P = .59). CONCLUSIONS: Not enough patients (only 85%) who receive colonoscopies are aware of their results or surveillance recommendations. Although awareness of findings and recommendations did not correlate with follow-up attendance, patients should be better informed about findings and their need for surveillance.
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Adenoma/diagnóstico , Neoplasias Colorrectales/diagnóstico , Detección Precoz del Cáncer/métodos , Conocimientos, Actitudes y Práctica en Salud , Aceptación de la Atención de Salud/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Encuestas y CuestionariosRESUMEN
OBJECTIVES: Colonoscopy is the gold standard for visualization of the colon. It is generally accepted as a safe procedure and major adverse events occur at a low rate. However, few data are available on structured assessment of (minor) post-procedural adverse events. METHODS: Consecutive outpatients undergoing colonoscopy were asked for permission to be called 30 days after their procedure. A standard telephone interview was developed to assess the occurrence of (i) major adverse events (hospital visit required), (ii) minor adverse events, and (iii) days missed from work. Adverse events were further categorized in definite-, possible-, and unrelated adverse events. Patients were contacted between January 2010 and September 2010. RESULTS: Out of a total of 1,528 patients who underwent colonoscopy and gave permission for a telephone call, 1,144 patients were contacted (response: 75%), 49% were male, the mean age was 59 years (s.d.: 14). Thirty-four patients (3%) reported major adverse events. These were definite-related in nine (1%) patients, possible-related in 6 (1%), and unrelated in 19 patients (2%). Minor adverse events were reported by 466 patients (41%). These were definite-related in 336 patients (29%), possible-related in 36 (3%), and unrelated in the remaining 94 patients (8%). Female gender (odds ratio (OR): 1.5), age <50 years (OR: 1.5), colonoscopy for colorectal cancer screening/surveillance (OR: 1.6), and fellow-endoscopy (OR: 1.7) were risk factors for the occurrence of any definite-related adverse event. Patients who reported definite-related adverse events were significantly less often willing to return for colonoscopy (81 vs. 88%, P<0.01) and were less often positive about the entire colonoscopy experience (84 vs. 89%, P=0.04). CONCLUSIONS: Structured assessment of post-colonoscopy adverse events shows that these are more common than generally reported. Close to one-third of patients report definite-related adverse events, which are major in close to 1 in 100 patients. The occurrence of adverse events does have an impact on the willingness to return for colonoscopy.
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Colonoscopía/efectos adversos , Pacientes Ambulatorios/estadística & datos numéricos , Anciano , Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/prevención & control , Femenino , Hospitales/estadística & datos numéricos , Humanos , Incidencia , Modelos Logísticos , Masculino , Persona de Mediana Edad , Países Bajos/epidemiología , Oportunidad Relativa , Garantía de la Calidad de Atención de Salud/normas , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores Sexuales , Encuestas y Cuestionarios , TeléfonoRESUMEN
BACKGROUND: Comprehensive monitoring of colonoscopy quality requires complete and accurate colonoscopy reporting. OBJECTIVE: This study aimed to assess the compliance with colonoscopy reporting and to assess the quality of colonoscopy performance. DESIGN: Consecutive colonoscopy reports were reviewed by hand. Four hundred reports were included from each department. SETTING: Daily clinical practice in 12 Dutch endoscopy departments. PATIENTS: Consecutive patients undergoing scheduled colonoscopy procedures. MAIN OUTCOME MEASUREMENTS: Quality of reporting was assessed by using the American Society for Gastrointestinal Endoscopy criteria for colonoscopy reporting. Quality of colonoscopy performance was evaluated by using the cecal intubation rate and adenoma detection rate (ADR). RESULTS: A total of 4800 colonoscopies were performed by 116 endoscopists: 70% by gastroenterologists, 16% by gastroenterology fellows, 10% by internists, 3% by nurse-endoscopists, and 1% by surgeons. The mean age of the patients was 59 years (standard deviation 16), and 47% were male. Reports contained information on indication, sedation practice, and extent of the procedure in more than 90%. Only 62% of the reports mentioned the quality of bowel preparation (range between departments 7%-100%); photographic documentation of the cecal landmarks was present in 71% (range 22%-97%). The adjusted cecal intubation rate was 92% (range 84%-97%). The ADR was 24% (range 13%-32%). LIMITATIONS: Dependent on reports, no intervention in endoscopic practice. No analysis for performance per endoscopist. CONCLUSION: Colonoscopy reporting varied significantly in clinical practice. Colonoscopy performance met the suggested standards; however, considerable variability between endoscopy departments was found. The results of this study underline the importance of the implementation of quality indicators and guidelines. Moreover, by continuous monitoring of quality parameters, the quality of both colonoscopy reporting and colonoscopy performance can easily be improved.
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Colonoscopía/normas , Documentación/normas , Garantía de la Calidad de Atención de Salud , Indicadores de Calidad de la Atención de Salud , Informe de Investigación/normas , Adulto , Anciano , Ciego , Sedación Profunda , Femenino , Adhesión a Directriz , Humanos , Intubación Gastrointestinal , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Países Bajos , Fotograbar , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
BACKGROUND AND AIMS: The dose and duration of mesalazine treatment for ulcerative colitis (UC) is a potentially important determinant of effectiveness, with evidence suggesting that continuing the induction dose for 6-12 months may improve outcomes; however, real-world data are lacking. We assessed mesalazine use in Dutch clinical practice, including how differences in dose and duration affected UC outcomes. METHODS: Adults with mild-to-moderate UC who received oral prolonged-release mesalazine de novo or had a dose escalation for an active episode were followed for 12 months in this non-interventional study (ClinicalTrials.gov identifier: NCT02261636). The primary endpoint was time from start of treatment to dose reduction (TDR). Secondary endpoints included recurrence rate, adherence, and work productivity. RESULTS: In total, 151 patients were enrolled, of whom 108 (71.5%) were newly diagnosed with UC. The majority (120; 79.5%) received a dose of ≥4 g/day. Nearly one-third (48; 31.8%) underwent dose reduction, with mean TDR being 8.3 months. Disease extent and endoscopic appearance did not influence duration of induction therapy, while TDR increased with higher baseline UCDAI scores. TDR was longer in patients without (mean 8.8 months) than with (4.1 months) recurrence, although not significantly (p=0.09). Patients on ≥4 g/day had a significantly lower chance of recurrence versus those on 2-<4 g/day (26.6% vs 62.5%, respectively; p=0.04). Longer treatment duration was associated with significantly reduced recurrence risk [hazard ratio >6 months vs 3-6 months: 0.19 (95%CI: 0.08-0.46); p<0.05], particularly for those on ≥4 g/day [0.15 (0.06-0.40) vs 0.26 (0.01-11.9) for 2-<4 g/day). Patients reported significantly increased work productivity, which was maintained throughout follow-up. CONCLUSIONS: Mesalazine was effective induction therapy, with treatment duration not meaningfully influenced by disease extent and endoscopic appearance at initiation. A higher induction dose of oral mesalazine (≥4 g/day) and longer duration of treatment (>6 months) was associated with a lower recurrence risk.
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Colitis Ulcerosa , Mesalamina , Administración Oral , Adulto , Antiinflamatorios no Esteroideos/efectos adversos , Colitis Ulcerosa/diagnóstico , Colitis Ulcerosa/tratamiento farmacológico , Duración de la Terapia , Humanos , Mesalamina/efectos adversos , Inducción de Remisión , Resultado del TratamientoRESUMEN
Recommendations in Barrett's esophagus (BE) guidelines are mainly based on male patients. We aimed to evaluate sex differences in BE patients in (1) probability of and (2) time to neoplastic progression, and (3) differences in the stage distribution of neoplasia. We conducted a multicenter prospective cohort study including 868 BE patients. Cox regression modeling and accelerated failure time modeling were used to estimate the sex differences. Neoplastic progression was defined as high-grade dysplasia (HGD) and/or esophageal adenocarcinoma (EAC). Among the 639 (74%) males and 229 females that were included (median follow-up 7.1 years), 61 (7.0%) developed HGD/EAC. Neoplastic progression risk was estimated to be twice as high among males (HR 2.26, 95% CI 1.11-4.62) than females. The risk of HGD was found to be higher in males (HR 3.76, 95% CI 1.33-10.6). Time to HGD/EAC (AR 0.52, 95% CI 0.29-0.95) and HGD (AR 0.40, 95% CI 0.19-0.86) was shorter in males. Females had proportionally more EAC than HGD and tended to have higher stages of neoplasia at diagnosis. In conclusion, both the risk of and time to neoplastic progression were higher in males. However, females were proportionally more often diagnosed with (advanced) EAC. We should strive for improved neoplastic risk stratification per individual BE patient, incorporating sex disparities into new prediction models.
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Background and study aims Gastric cancer (GC) is usually preceded by premalignant gastric lesions (GPLs) such as gastric intestinal metaplasia (GIM). Information on risk factors associated with neoplastic progression of GIM are scarce. This study aimed to identify predictors for progression of GIM in areas with low GC incidence. Patients and methods The Progression and Regression of Precancerous Gastric Lesions (PROREGAL) study includes patients with GPL. Patients underwent at least two upper endoscopies with random biopsy sampling. Progression of GIM means an increase in severity according to OLGIM (operative link on gastric intestinal metaplasia) during follow-up (FU). Family history and lifestyle factors were determined through questionnaires. Serum Helicobacter pylori infection, pepsinogens (PG), gastrin-17 and GC-associated single nucleotide polymorphisms (SNPs) were determined. Cox regression was performed for risk analysis and a chi-squared test for analysis of single nucleotide polymorphisms. Results Three hundred and eight patients (median age at inclusion 61 years, interquartile range (IQR: 17; male 48.4â%; median FU 48 months, IQR: 24) were included. During FU, 116 patients (37.7â%) showed progression of IM and six patients (1.9â%) developed high-grade dysplasia or GC. The minor allele (C) on TLR4 (rs11536889) was inversely associated with progression of GIM (OR 0.6; 95â%CI 0.4-1.0). Family history (HR 1.5; 95â%CI 0.9-2.4) and smoking (HR 1.6; 95â%CI 0.9-2.7) showed trends towards progression of GIM. Alcohol use, body mass index, history of H. pylori infection, and serological markers were not associated with progression. Conclusions Family history and smoking appear to be related to an increased risk of GIM progression in low GC incidence countries. TLR4 (rs11536889) showed a significant inverse association, suggesting that genetic information may play a role in GIM progression.
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AIM: To quantify lymphovascular invasion (LVI) and to assess the prognostic value in patients with pT1b esophageal adenocarcinoma. METHODS: In this nationwide, retrospective cohort study, patients were included if they were treated with surgery or endoscopic resection for pT1b esophageal adenocarcinoma. Primary endpoint was the presence of metastases, lymph node metastases, or distant metastases, in surgical resection specimens or during follow-up. A prediction model to identify risk factors for metastases was developed and internally validated. RESULTS: 248 patients were included. LVI was distributed as follows: no LVI (n = 196; 79.0%), 1 LVI focus (n = 16; 6.5%), 2-3 LVI foci (n = 21; 8.5%) and ≥4 LVI foci (n = 15; 6.0%). Seventy-eight patients had metastases. The risk of metastases was increased for tumors with 2-3 LVI foci [subdistribution hazard ratio (SHR) 3.39, 95% confidence interval (CI) 2.10-5.47] and ≥4 LVI foci (SHR 3.81, 95% CI 2.37-6.10). The prediction model demonstrated a good discriminative ability (c-statistic 0.81). CONCLUSION: The risk of metastases is higher when more LVI foci are present. Quantification of LVI could be useful for a more precise risk estimation of metastases. This model needs to be externally validated before implementation into clinical practice.