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BACKGROUND AND AIMS: Resection of colorectal polyps has been shown to decrease the incidence and mortality of colorectal cancer. Large nonpedunculated colorectal polyps are often referred to expert centers for endoscopic resection, which requires relevant information to be conveyed to the therapeutic endoscopist to allow for triage and planning of resection technique. The primary objective of this study was to establish minimum expected standards for the referral of large nonpedunculated colonic polyps for potential endoscopic resection. METHODS: A Delphi method was used to establish consensus on minimum expected standards for the referral of large colorectal polyps among a panel of international endoscopy experts. The expert panel was recruited through purposive sampling, and 3 rounds of surveys were conducted to achieve consensus. Quantitative and qualitative data were analyzed for each round. RESULTS: A total of 24 international experts from diverse continents participated in the Delphi study, resulting in consensus on 19 statements related to the referral of large colorectal polyps. The identified factors, including patient demographic characteristics, relevant medications, lesion factors, photodocumentation, and the presence of a tattoo, were deemed important for conveying the necessary information to therapeutic endoscopists. The mean scores for the statements, which were scored on a scale of 1 to 10, ranged from 7.04 to 9.29, with high percentages of experts considering most statements as a very high priority. Subgroup analysis according to continent revealed some variations in consensus rates among experts from different regions. CONCLUSIONS: The identified consensus statements can aid in improving the triage and planning of resection techniques for large colorectal polyps, ultimately contributing to the reduction of colorectal cancer incidence and mortality.
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Pólipos do Colo , Colonoscopia , Consenso , Técnica Delphi , Encaminhamento e Consulta , Humanos , Pólipos do Colo/cirurgia , Pólipos do Colo/patologia , Encaminhamento e Consulta/normas , Colonoscopia/normas , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/patologiaRESUMO
BACKGROUND AND AIM: Colorectal cancer (CRC) diagnosed following a cancer-negative colonoscopy is termed as post-colonoscopy CRC (PCCRC). The World Endoscopy Organization has recently standardized the definition of PCCRC-3Y (CRC developing within 3 years of a cancer-negative colonoscopy). In the present study, we sought to assess PCCRC-3Y rate, perform root-cause analyses, and identify factors associated with development of PCCRC at a tertiary referral hospital in Australia. METHODS: All patients undergoing colonoscopy from 2011 to 2018 were matched to a population-based cancer register. PCCRC-3Y rate was assessed for years 2011-2015. All PCCRC cases that developed within 6-48 months after a cancer-negative colonoscopy underwent root-cause analyses. Descriptive statistics were used to summarize data. RESULTS: Among 17 828 patients undergoing colonoscopy, 367 CRC cases were diagnosed during the study period. This included nine PCCRC cases, which developed at a median of 14 months (range 7-34 months) after cancer-negative colonoscopy. The PCCRC-3Y rate for years 2011-2015 was 2.16% (95% CI 0.91-5.15). All nine PCCRC cases were moderately or poorly differentiated adenocarcinomas; seven of nine were early-stage CRC (stages I and II) and six of nine probably represented missed lesions at index colonoscopy despite an apparently adequate examination. History of inflammatory bowel disease (IBD) (odds ratio [OR] 21.9, 95% confidence interval [CI] 4.6-103.7, P < 0.001) and diverticulosis (OR 5.4, 95% CI 1.4-20.5, P = 0.01) were significantly associated with development of missed CRC. CONCLUSIONS: In our tertiary referral colonoscopy cohort, PCCRC-3Y rate was 2.16% (95% CI 0.91-5.15). IBD and diverticulosis were significantly associated with risk of PCCRC. The majority of PCCRC lesions were likely missed at index colonoscopy, despite an apparently adequate examination.
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Neoplasias Colorretais , Doenças Inflamatórias Intestinais , Humanos , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/epidemiologia , Neoplasias Colorretais/etiologia , Estudos Retrospectivos , Centros de Atenção Terciária , Fatores de Risco , Colonoscopia , Austrália/epidemiologia , Armazenamento e Recuperação da Informação , Detecção Precoce de CâncerRESUMO
OBJECTIVE: High-quality gastroscopy is critical for early diagnosis of upper gastrointestinal cancers (UGCs), and assessment of missed cancers may serve as a key quality metric. Using a prospective gastroscopy database and data linkage with the Queensland Cancer Registry, we assessed the risk of developing UGC within 3 years of a cancer-negative gastroscopy at an Australian tertiary centre. Additional aims were to identify factors predictive of missed cancer, perform root cause analyses for missed cancers and assess overall survival. DESIGN/METHOD: We identified patients who were diagnosed with UGC within 3 years of undergoing gastroscopy between 2011 and 2016. Non-mucosal cancers, cancers distal to duodenum and patients undergoing surveillance were excluded. Cases diagnosed within 6 months of gastroscopy were defined as detected cancers, while those developing within 6-36 months were defined as missed cancers. Post-endoscopy UGC rate (PEUGIC-3Y) was calculated as ratio of missed over total cancers detected. Demographic, clinical, endoscopic and histologic variables were analysed. RESULTS: A total of 17,131 gastroscopies were performed for 10,393 patients during the study period. One hundred and twenty-six UGCs were diagnosed, including 120 detected UGCs and 6 missed UGCs. The overall PEUGIC-3Y rate was 4.8% (95% CI 2.1-10.4). The missed UGCs included 3 gastric adenocarcinomas, 2 gastro-oesophageal junction adenocarcinomas and 1 oesophageal squamous cell carcinoma. At the preceding 'cancer-negative gastroscopy', no macroscopic abnormalities were detected at the site of future UGC in 5/6 patients. A UGC developed in 2/6 patients despite an apparent adequate examination at index gastroscopy. Age, sex, indication for endoscopy and cancer location or histology were not predictive of missed cases, and survival was comparable between groups. CONCLUSION: We demonstrate that the PEUGIC-3Y rate was 4.8% (95% CI 2.1-10.4). The majority of missed cases were adenocarcinomas of the gastro-oesophageal junction or stomach and developed in segments which were found to be normal at index gastroscopy, highlighting the challenges in detecting subtle mucosal lesions in the upper gastrointestinal tract. While overall survival between patients with detected and post-gastroscopy cancers was comparable, these ultimately represent potential missed opportunities for diagnosing an early cancer and underscore the need for quality improvement in gastroscopy.
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Adenocarcinoma , Neoplasias Gastrointestinais , Neoplasias Gástricas , Trato Gastrointestinal Superior , Humanos , Estudos Prospectivos , Centros de Atenção Terciária , Austrália/epidemiologia , Endoscopia Gastrointestinal , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/epidemiologia , Neoplasias Gástricas/patologia , Gastroscopia , Trato Gastrointestinal Superior/patologia , Adenocarcinoma/diagnóstico , Adenocarcinoma/epidemiologia , Armazenamento e Recuperação da Informação , Estudos RetrospectivosRESUMO
Background and Aims: Sessile serrated lesions (SSLs) develop colorectal cancer (CRC), through a critical intermediary stage of SSL with dysplasia (SSLd). In this prospective observational study, we aimed to assess clinicopathological correlates of SSLd in the setting of a high lesion-detection rate. Methods: Patients diagnosed with SSL and SSLd from February 2018 until January 2020 were prospectively recruited, and SSLd specimens were re-evaluated by 2 expert pathologists in a blinded manner. Associations were analyzed using multivariate logistic regression models. Results: A total of 6425 patients underwent 7423 colonoscopies, and 2671 SSLs were resected from 1047 patients. The overall SSL detection rate per colonoscopy was 15.9%. The median age of patients with SSL was 54 years (interquartile range, 39-66), and 43.3% were male. After pathologist review, 24 SSLds were confirmed in 20 patients. The median size of SSLd was 8 mm (interquartile range, 5.75-15.25), and 13 of 24 SSLds were <10 mm in size. After multivariate analysis, older age (odds ratio = 1.07, 95% confidence interval = 1.03-1.1) and higher number of synchronous SSLs (odds ratio = 1.12, 95% confidence interval = 1.02-1.23) were associated with the presence of dysplasia. Patient sex and number and size of synchronous adenomas were not associated with the presence of SSLd. Seven of 20 patients with SSLd had synchronous or metachronous SSLd. Six of 20 patients with SSLd met the diagnostic criteria for serrated polyposis syndrome. Conclusion: The overall SSL detection rate was 15.9%, and 0.9% of SSLs were dysplastic. Older age and higher number of synchronous SSL were risk factors for the presence of dysplasia in SSLs. Thirty percent of patients with SSLd had serrated polyposis syndrome, and 35% had multiple SSLd.
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BACKGROUND: Autoimmune markers including plasma cells (PC), anti-smooth-muscle antibody (ASMA), anti-nuclear antibody (ANA), and raised immunoglobulin G (IgG) are commonly observed in non-alcoholic steatohepatitis (NASH), however their clinical significance is unknown. AIM: To determine if autoimmune markers in NASH patients are independently associated with poorer clinical outcomes. METHODS: Consecutive patients with biopsy proven NASH from Christchurch Hospital, New Zealand and Singapore General Hospital (SGH) were included between 2005 to 2016 in a prospective multi-centre cohort study. Patients with other causes of chronic liver disease were excluded. IgG > 14 g/L or globulin fraction > 50%, ANA ≥ 1:40, SMA ≥ 1:40 were considered positive. Multivariate analysis was performed to assess which markers were independently associated with mortality and hepatic decompensation. RESULTS: Total 261 patients were included of which 201 were from SGH. The median age was 53 and 51.9% were male. Advanced fibrosis was present in 31.4% at diagnosis. PC, ASMA, ANA and raised IgG were observed in 13.1%, 4.9%, 27.8% and 30.1% of patients respectively. After multivariate analysis, elevated IgG [Hazard Ratio (HR) 6.79, 95%CI: 2.93-17.15] and fibrosis stage (HR 1.37, 95%CI: 1.03-1.87) were found to be independently associated with increased risk of liver decompensation. Age (HR 1.06, 95%CI: 1.02-1.10) and elevated IgG (HR 3.79, 95%CI: 1.90-7.68) were independent factors associated with higher mortality risk. CONCLUSION: Elevated IgG, rather than ANA, ASMA or plasma cells, is independently associated with increased risk of hepatic decompensation and mortality in NASH. It could hence be important for prognostication.
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Hepatopatia Gordurosa não Alcoólica , Estudos de Coortes , Humanos , Imunoglobulina G , Fígado/patologia , Cirrose Hepática/diagnóstico , Cirrose Hepática/patologia , Masculino , Hepatopatia Gordurosa não Alcoólica/diagnóstico , Hepatopatia Gordurosa não Alcoólica/epidemiologia , Hepatopatia Gordurosa não Alcoólica/patologia , Estudos ProspectivosRESUMO
Background and study aims Gastroesophageal reflux disease (GERD) is common, especially in patients after gastric surgery. Medical management of GERD is ineffective in up to 30â% patients and revisional gastric surgery for management of GERD is associated with higher morbidity. We aimed to assess the safety, feasibility, and efficacy of a novel endoscopic resection and plication (RAP) anti-reflux procedure for management of medically refractory GERD in patients with altered gastric anatomy. Patients and methods The RAP procedure involves endoscopic mucosal resection and full-thickness plication over the right posterior-medial axis extending 15âmm above and 20 to 30âmm below the squamocolumnar junction. Adverse events, technical feasibility, GERD health-related quality-of-life (GERD-HRQL) scores, and medication use were prospectively recorded. Results Twenty consecutive patients with previous gastric surgery underwent RAP between September 2018 and August 2020 with a median follow-up of 5.7 months. The median procedure duration was 66 minutes (IQR 53.8-89.5). RAP was technically successful in 19 patients. One patient developed gastric hemorrhage from suture dehiscence, which was managed endoscopically, and four patients developed esophageal stricture requiring endoscopic dilation. Following the RAP procedure, significant improvement in GERD-HRQL score was observed (mean 26.9, 95â%CI 23.36-30.55, P â<â0.01). Fourteen of 19 patients reported > 50â% improvement in GERD-HRQL scores. Sixteen of 18 patients reported reduction in requirement for or cessation of antacid therapy. Conclusions Patients with refractory GERD after gastric surgery have limited therapeutic options. We have demonstrated that the RAP procedure is feasible, safe, and clinically effective at short-term follow-up. It provides a potential alternative to revisional surgery in patients with altered gastric anatomy.
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BACKGROUND: Patients with pulmonary embolism (PE) have increased mortality in short-term; however, long-term prognosis is not well defined. AIM: In this long-term cohort study, we aimed to determine if PE was associated with increased risk of mortality or serious clinical events (SCE). Secondary aims were to ascertain predictors of mortality and SCE. METHODS: Patients admitted with clinical suspicion of PE were prospectively recruited from July 2002 to May 2003 and followed up until March 2015. Clinical outcomes in patients with PE were compared to those without PE. SCE was defined as composite of mortality, malignancy, cardiovascular events, recurrent venous thromboembolism and chronic thromboembolic pulmonary hypertension. RESULTS: A total of 501 patients with median follow up of 11.9 years (interquartile range 3.91-12.28) was included. PE was diagnosed in 104 (20.7%) patients. Overall, 45.9% died and 57.1% developed SCE during follow up, with no significant difference in PE and no-PE groups (both P > 0.5). Major determinants of mortality were age (hazard ratio (HR) 1.06 per year, 95% confidence interval (CI) 1.05-1.08), malignancy (HR 2.19, 95% CI 1.64-2.91) and congestive heart failure (HR 1.72, 95% CI 1.23-2.42). Factors associated with increased risk of SCE were age (HR 1.05 per year, 95% CI 1.04-1.06), malignancy (HR 1.93, 95% CI 1.48-2.52) and congestive heart failure (HR 1.77, 95% CI 1.29-2.43). In patients without PE, elevated D-dimer concentration was not found to be associated with diagnosis of malignancy during follow up (HR 1.31, 95% CI 0.55-3.12). CONCLUSIONS: In this prospective study, we did not find association between PE and risk of all-cause mortality or SCE. Major determinants of poor clinical outcomes were advancing age and underlying comorbidities.
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Embolia Pulmonar , Tromboembolia Venosa , Estudos de Coortes , Humanos , Estudos Longitudinais , Estudos Prospectivos , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/epidemiologia , Fatores de RiscoRESUMO
BACKGROUND & AIMS: Lynch syndrome is the most common inherited cause of colorectal cancer (CRC). Contemporary and mutation-specific estimates of CRC-risk in patients undergoing colonoscopy would optimize surveillance strategies. We performed a prospective national cohort study, using data from New Zealand, to assess overall and mutation-specific risk of CRC in patients with Lynch syndrome undergoing surveillance. METHODS: We performed a prospective study of 381 persons with Lynch syndrome in New Zealand (98 with Lynch-syndrome associated variants in MLH1, 159 in MSH2, 103 in MSH6, and 21 in PMS2). Participants were offered annual colonoscopy starting at age 25 y, and those who underwent 2 or more colonoscopies before December 31, 2017 were included in the final analysis. Patients with previous colonic resection, history of CRC or diagnosis of CRC at index colonoscopy were excluded. RESULTS: Study participants underwent 2061 colonoscopies during 2296 person-y; the median observation-period was 4.43 y and mean-age at enrollment was 43 y. Eighteen patients developed CRC (8 with variants in MLH1, 8 in MSH2, and 2 in MSH6) after a median follow-up period of 6.5 y (range 1-16 y). Eighty-three percent of patients had a surveillance colonoscopy in preceding 24 months before diagnosis of CRC; 94% were diagnosed with stage 0-II CRC and there was no CRC-related mortality. The overall-risk of developing CRC in the 5 y after first surveillance colonoscopy was 2.49% (95% CI, 1.18-5.23); cumulative risks for CRC in patients with Lynch syndrome-associated variants in MLH1, MSH2, or MSH6 by age 70 y were 17.7%, 17.8%, and 8.5%, respectively. Age-adjusted CRC-risk in patients with variants in MSH6 was lower than in MLH1 (hazard ratio, 0.2; 95% CI, 0.04-0.94; P = .02). Of patients with CRC, 33% had an adenomatous polyp resected from same segment in which a colorectal tumor later developed. CONCLUSIONS: The risk of CRC in patients with Lynch syndrome-associated mutations in MSH6 or PMS2 was significantly lower than in patients with mutations in MLH1. Incomplete adenomatous polyp resection might be responsible for one third of surveillance-detected CRCs.
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Neoplasias Colorretais , Reparo de Erro de Pareamento de DNA , Adulto , Idoso , Estudos de Coortes , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/epidemiologia , Neoplasias Colorretais/genética , Proteínas de Ligação a DNA/genética , Humanos , Endonuclease PMS2 de Reparo de Erro de Pareamento/genética , Proteína 1 Homóloga a MutL , Mutação , Estudos ProspectivosRESUMO
AIMS: Outpatient endoscopy non-attendance leads to diagnostic delay and increasing wait times. We aimed to analyse endoscopy non-attendance rates and factors associated with it at the Canterbury and Auckland District Health Boards during a five-year period. METHODS: Consecutive appointments between April 2012 and March 2017 were assessed. The following procedures were included: gastroscopy, colonoscopy and endoscopic retrograde cholangiopancreatography. Predictors of non-attendance were assessed using univariate and multivariate binary logistic regression. RESULTS: A total of 58,434 appointments were offered (Canterbury-33,697, Auckland-24,737), of which 2,694 (4.6%) were not attended. Maori (OR 3.0, 95%CI 2.63-3.42) and Pacific Peoples (OR 3.1, 95%CI 2.7-3.55) were significantly more likely to miss appointments compared with Europeans. Patients from socioeconomically most deprived areas (NZDep10) had higher rates of non-attendance (OR 2.13, 95%CI 1.72-2.63) compared with NZDep1. Males (OR 1.43, 95%CI 1.32-1.56) and the Auckland District Health Board patients (OR 2.28, 95%CI 2.08-2.50) had higher non-attendance rates. CONCLUSION: Overall, 4.6% patients did not attend endoscopy appointments. Maori, Pacific Peoples and patients from socioeconomically deprived areas had higher non-attendance rates. Targeted interventions for at-risk groups would potentially lessen health inequalities and optimise utilisation of endoscopy resources.
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Agendamento de Consultas , Diagnóstico Tardio/estatística & dados numéricos , Endoscopia do Sistema Digestório/métodos , Cooperação do Paciente/estatística & dados numéricos , Adulto , Assistência Ambulatorial/organização & administração , Análise de Variância , Endoscopia do Sistema Digestório/estatística & dados numéricos , Etnicidade , Feminino , Hospitais Públicos , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Nova Zelândia , Pacientes Ambulatoriais/estatística & dados numéricos , Sistemas de Alerta , Estudos Retrospectivos , Medição de Risco , Fatores SocioeconômicosRESUMO
AIMS: To perform an independent review of the quality and safety of colonoscopy service at the Canterbury Charity Hospital (CCH). METHODS: Demographic, endoscopy and histology data on all colonoscopies performed at CCH between 1 October 2016 and 31 September 2017 were collected. Quality indicators ascertained were caecal intubation rate, mean withdrawal time and adenoma detection rate (ADR). These were assessed using current recommendations by the Joint American College of Gastroenterology and American Society of Gastrointestinal Endoscopy task force. RESULTS: Thirty-four patients, mean age 44 years (range 21-62), underwent colonoscopy. The most common indications were rectal bleeding and/or altered bowel habit (19 patients). Eight asymptomatic patients underwent colonoscopy because of a family history of CRC or a personal history of colorectal polyps; six of these were over 50 years old. Twelve patients had haemorrhoids and seven patients had adenomatous polyps. The caecal intubation rate was 97.1%. Among asymptomatic patients over 50 years undergoing colonoscopy, mean withdrawal time was 7.5 minutes (range 5-10) and ADR was 33.3%. No complications were recorded. CONCLUSION: The colonoscopy service at CCH was safe and complied with the accepted quality indicators. Our data suggest that delivery of high-quality colonoscopy services might be possible in similar peripheral and day hospitals around New Zealand. Increasing colonoscopy services in such centres would reduce the excessive workload of larger public hospitals and reduce the level of unmet need for colonoscopy services.