Impact of an Endoscopic Quality Improvement Program Focused on Adenoma Detection on Sessile Serrated Adenoma/Polyp Detection.

BACKGROUND: Sessile serrated adenomas/polyps (SSA/P) are an under-recognized disease with a unique malignant pathway. Improved endoscopic recognition and pathological interpretation is needed. AIMS: To determine whether an educational intervention that improved adenoma detection rate (ADR) could improve SSA/P detection rate after reclassification of previously termed "hyperplastic" polyps. METHODS: We reanalyzed data from a prospective randomized trial of an educational intervention aimed at increasing ADR. All hyperplastic polyps ≥6 mm reported in a previously published study were rereviewed and reclassified using standardized criteria for serrated lesions. Detection rates of sessile serrated adenomas/polyps and other clinically relevant serrated polyps were calculated in the baseline and post-training phases of the original study. RESULTS: Of 263 available for rereview, 33 (12.5%) were reclassified as SSA/P (N = 32) or traditional serrated adenoma (TSA) (N = 1). Reclassification was more common in the right colon (18 vs. 8%, p = 0.02). Baseline SSA/P detection rate was 0.7% in the untrained group and 1.3% in the trained group. Post-training, the SSA/P detection rate increased to 2.1 and 1.5%, respectively. The clinically relevant serrated polyp detection rate at baseline was 14.2% in the untrained group and 11.3% in the trained group. After the educational intervention, the clinically relevant serrated polyp detection rates increased to 16.5 and 14.8% in the untrained and trained groups, respectively. The estimated odds of an endoscopist detecting either a SSA/P or other clinically relevant serrated polyp during colonoscopy increased by only 3% with the educational intervention (OR 1.03, 95% CI 0.61-1.74, p = 0.91). CONCLUSIONS: Pathological re-interpretation of larger serrated polyps resulted in the reclassification of 12.5% of lesions. Quality improvement methods focused on adenoma detection did not impact SSA/P detection, and thus specific methods for serrated polyp detection are needed.

Electrophoretic characterization of the Mammalian nuclear matrix proteome, nuclear envelope, nucleoli and covalently bound ADP-ribose polymers: potential applications to cancer.

BACKGROUND/AIM: Nucleic acid metabolism is biochemically compartmentalized to the nucleus. Thus, it is necessary to define the proteome of the various macromolecular structures within this organelle. MATERIALS AND METHODS: We isolated the nuclear matrix (NM) fraction from rat liver by sequential centrifugation steps at 13,000 rpm, staggered between endogenous nuclease treatment for 2 h at 37°C, followed by high-salt (H.S.; 2.0 M NaCl) and non-ionic detergent extractions (0.1%- or 1.0% Triton X-100) to eliminate the bulk of chromosomal DNA/RNA, histone proteins and the nuclear envelope (NE). RESULTS: Integrity of the NM and NE structures was confirmed by electron microscopy. Next, we analyzed the NM proteome on a 20% polyacrylamide gel using the PhastSystem. We observed the absence of histone proteins and the characteristic presence of the lamins by Coomassie blue staining. By contrast, upon silver staining, following electrophoretic separation with a Tris-Borate-EDTA buffer, we observed the NM-associated nucleic RNA and protein-free ADP-ribose polymers. While polymers are found in much lower concentration than RNA in NM, they were purified by affinity chromatography on boronate resin prior to electrophoresis. We observed the electrophoretic resolution of free ADP-ribose chains (5-25 units) by silver staining. CONCLUSION: The significance of our observations to cancer studies and carcinogenesis is discussed.

High-definition white-light (HDWL) colonoscopy and higher adenoma detection rate and the potential for paradoxical over surveillance.

BACKGROUND: Patients undergoing high-definition white-light colonoscopy by a high adenoma detector may have a lower risk of interval adenoma detection on follow-up colonoscopy and may require less frequent follow-up but may paradoxically be assigned to more frequent surveillance when more adenomas are detected. AIMS: To evaluate whether high-definition white-light colonoscopy (vs. standard-definition white-light colonoscopy) and endoscopist adenoma detection rate (ADR) at index colonoscopy are associated with increased likelihood of adenomas at follow-up. METHODS: Longitudinal follow-up of prior cross-section cohort study of patients who underwent colonoscopy at baseline with at least one detected adenoma was included. Associations of type of white-light at index colonoscopy and the ADR of the endoscopist at index colonoscopy (high vs. low adenoma detector) were evaluated with various adenoma and polyp detection endpoints. Eighteen endoscopists were classified as high and low adenoma detectors based on the median ADR of 0.255. RESULTS: There were no significant differences in subsequent interval adenoma or polyp detection endpoints with regard to whether baseline exam was performed with high-definition white-light or standard-definition white-light colonoscopy nor between high and low ADR after adjusting for multiple testing (P ≤ 0.0029 considered significant). Prior to multiple testing adjustment, there was a significantly lower detection rate of hyperplastic polyps in the left colon (24 vs. 35 %, OR: 0.56, P = 0.033) at follow-up colonoscopy when baseline exam was performed with high-definition white-light index colonoscopy. CONCLUSIONS: The results of this study do not support adjusting colonoscopy surveillance guidelines based on type of colonoscopy performed or the endoscopist's ADR.

Colonic endoscopic mucosal resection of large polyps: Is it safe in the very elderly?

BACKGROUND: Outcomes on colon endoscopic mucosal resection in the very elderly patient population are unknown. AIMS: Aims of this study were to evaluate the outcomes and safety of colon endoscopic mucosal resection in this target population. METHODS: Observational, retrospective study of patients ≥ 80 years of age that underwent colon endoscopic mucosal resection ≥ 2 cm. Demographics, American Society of Anesthesiologists classification, procedural data, and surgical treatment data were collected. RESULTS: One-hundred-and-thirty-one colon endoscopic mucosal resections were performed on 99 patients ≥ 80 years of age with a mean age of 84. The majority of American Society of Anesthesiologists class was II. Mean lesion size was 3.3 cm (range, 2-12.5 cm), more procedures were performed in the right colon and adenoma/tubulovillous adenoma was the most common pathology. En bloc resection was performed on 26.7% of polyps (N=35). Eight procedure-related adverse events (8/131, 6.1%) occurred. No anaesthesia related adverse events or deaths occurred. Six patients required a colonic operation, and overall, 94% of the patient cohort evaded a colon operation. CONCLUSIONS: Colon endoscopic mucosal resection in very elderly patients can be performed at experienced endoscopy centres with a low rate of complications and offers these patients a non-surgical option of management of colorectal lesions.