Establishment of standards for the referral of large nonpedunculated colorectal polyps: an international expert consensus using a modified Delphi process.

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.

Outcomes of patients with delayed surveillance colonoscopy.

BACKGROUND: Surveillance colonoscopy has been shown to be an effective tool for prevention of colorectal cancer (CRC) in high-risk populations, if adhered to. AIM: To discover the sequelae of late surveillance in a cohort of patient's overdue for colonoscopy. METHODS: We conducted a retrospective cohort study on all patients from the Bay of Plenty District Health Board region, New Zealand, placed on the colonoscopy surveillance waitlist from 2006 onwards who had their procedure completed between 1 November 2016 and 31 January 2018. Patients with overdue surveillance, defined as done later than 90 days after the recommended due date, were compared with patients who were done either early or on time. RESULTS: A total of 786 patients was recorded as overdue for surveillance colonoscopy and 386 were completed early or on time. The median time overdue was 22 months. Three (0.4%) cases of CRC were found in overdue patients compared with four (1%) cases for those done on time (adjusted P = 0.24). There were 86 (11%) advanced adenomas (AA) in patients overdue compared with 27 (7%) in those not overdue (odds ratio (OR) 1.6; 95% confidence interval (CI) 1.0-2.5; P = 0.04). Surveillance of 180 high-risk post-polypectomy patients identified 2 CRC and 8/43 AA in those overdue compared with no CRC and 9/137 AA (18.6% vs 6.6%; OR 1.79; 95% CI 1.07-2.0; unadjusted P = 0.03) in those done on time. CONCLUSION: While overdue surveillance is not predictive of increased CRC, it is associated with an increase in expected number of AA, particularly in patients having surveillance for previous high-risk polypectomy.

A comparison of intravenous methylprednisolone and hydrocortisone for the treatment of acute inflammatory bowel disease.

BACKGROUND AND AIM: Despite widespread recommendations and use of intravenous corticosteroids (IVCS) for the treatment of acute flares of ulcerative colitis and Crohn's disease, limited evidence exists comparing outcomes of the two most common regimens, intravenous methylprednisolone (IVMP) and intravenous hydrocortisone (IVHC). IVHC has stronger mineralocorticoid effects compared with IVMP and may cause higher rates of hypokalemia. We aimed to determine differences in clinical outcomes including requirement for inpatient rescue therapy, bowel resection, and rates of hypokalemia. METHODS: We conducted a multicenter cohort study of all adult patients admitted with an acute flare of inflammatory bowel disease (IBD) to the three tertiary hospitals in Auckland, New Zealand, where the protocol at each institution is either IVMP 60 mg daily or IVHC 100 mg four times daily. All patients requiring IVCS between 20 June 2016 and 30 June 2018 were included. The IVCS protocol was then changed at one hospital, where further data were collected for a further 12 months from 30 January 2019 until 30 December 2019. RESULTS: There were 359 patients, including 129 (35.9%) patients receiving IVMP and 230 (64.1%) patients receiving IVHC. IVMP treatment was associated with a greater requirement for rescue therapy than IVHC (36.4% vs 19.6%, P = 0.001; odds ratio [OR] = 2.79; 95% confidence interval [CI], 1.64-4.75, P < 0.001), but also reduced rates of hypokalemia (55.8% vs 67.0%, P = 0.04; OR = 0.49; 95% CI, 0.30-0.81, P = 0.005). There was no difference between treatment groups for the median length of admission (5 days, interquartile range [IQR] 3-8), median duration of IVCS treatment (3 days, IQR 2-5), or bowel resection within 30 days of admission (12.4% vs 11.7%; OR = 1.04). CONCLUSION: For the treatment of an acute flare of IBD, treatment with IVMP results in significantly more requirement for inpatient rescue biologic or cyclosporin. In addition, it causes statistically significant less hypokalemia than IVHC, although in practice differences are negligible.

Surveillance factors change outcomes in patients with hepatocellular carcinoma due to chronic hepatitis C virus infection in New Zealand.

Although surveillance for Hepatocellular Carcinoma (HCC) with 6 monthly imaging is recommended for patients with cirrhosis secondary to chronic hepatitis C virus (HCV) infection, international studies report poor adherence and there is paucity of data on its effect on patient outcomes. The primary aim of this study was to review cases of HCC secondary to HCV to determine the impact of adherence with HCC surveillance on survival. A total of 520 patients with confirmed HCC secondary to chronic HCV from 31 January 2001 to 31 May 2018 were identified from a prospective national HCC database. Computerized clinical records, general practitioner referral letters and secondary care clinic letters were subsequently retrospectively analysed for methods of HCC detection. HCC was detected through routine surveillance in only 224 patients (44%). HCC was detected either incidentally or following the onset of symptoms in nonadherent (12%), suboptimal surveyed (3%), undiagnosed cirrhotic (12%) or recently diagnosed HCV patients (21%) or were never offered surveillance (2%). Routine surveillance improved overall survival, OR 0.41 (95% CI [0.32, 0.53], P < .0001), with an overall mean survival of 91.5 months (95% CI 76.4, 106.6) compared to 43.0 (95% CI 34.2, 51.9) for those patients not receiving regular surveillance Outcome following diagnosis of HCC secondary to chronic HCV is determined by early detection when curative intervention is possible. Lack of diagnosis of HCV and nonadherence to HCC surveillance results in late diagnosis and poor outcomes. Under-diagnosis of HCV infection and lack of diagnosis of cirrhosis in patients known to have HCV infection reduce the benefit of current HCC surveillance strategies.

Predictors of symptom recurrence and survival in patients with malignant gastric outlet obstruction treated with self-expanding metal stents.

BACKGROUND: Malignant gastric outlet obstruction (GOO) poses a substantial symptomatic burden. While various therapeutic options exist, self-expanding metal stents (SEMS) are a common palliative choice for patients who are ineligible for surgery. We studied SEMS outcomes to identify factors influencing stent dysfunction and patient survival. METHODS: A multi-centre, retrospective review of 190 patients with GOO undergoing SEMS at three tertiary hospitals was performed over 2016-2022. Technical success, clinical success and adverse outcomes were recorded. Predictors of stent dysfunction and survival were evaluated using multivariate regression. RESULTS: Technical success was achieved in 186/190 (97.9%) and clinical success in 156/186 (83.9%), defined as post-procedural gastric outlet obstruction symptom score (GOOSS) ≥2. Eighty-two (44.1%) patients experienced an adverse event with stent occlusion the most common (23.1%). Approximately one-third (32.3%) underwent a repeat intervention. Mean stent patency time was 67 days (standard deviation=76), and median post-stent survival was 95 days (37-197). Covered and partially covered SEMS carried three times the risk of stent dysfunction compared to uncovered SEMS (odds ratio 3.06, p=0.008). Mortality predictors were Eastern Cooperative Oncology Group score ≥2 (p=0.03), extrinsic outlet obstruction (p=0.05) and presence of ascites (p=<0.001). CONCLUSION: SEMS demonstrated technical and clinical success but posed a high risk of recurrence, with stent patency time falling short of survival in our cohort. With an evolving landscape of therapeutics for GOO, appropriate patient selection is paramount. Individuals with reduced performance status, extrinsic obstruction and/or ascites may be better candidates for SEMS due to more limited life expectancy. In this setting, uncovered SEMS carry the lowest risk of reintervention.

Untutored learning curve for endoscopic submucosal dissection in New Zealand.

INTRODUCTION: Endoscopic submucosal dissection (ESD) is a specialised endoscopic technique in the treatment of large pre-cancerous and early cancerous gastrointestinal lesions that avoids the need for surgical resections. The objective of this study was to assess the feasibility, efficacy and safety of learning ESD in an untutored approach in a prevalence-based setting within New Zealand. METHODS: Over a 4-year period, 80 ESD procedures were performed at a single tertiary centre within New Zealand. We retrospectively reviewed basic demographics of the patients, along with successful en bloc resection rates, dissection speeds, histological diagnoses (including margin assessments) and complications. RESULTS: We captured 80 procedures. Within this database we achieved an en bloc resection of 88.7% (71 out of 80 cases) and an R0 resection of 72.5% (58 out of 80 cases). The international benchmark for dissection speed of 9cm2/h was achieved within the first block of 20 cases and was maintained throughout. There was a perforation rate of 6.25% (five patients), with one patient (1.25%) requiring emergency surgery for a rectal perforation. CONCLUSIONS: Our study shows it is feasible and safe to learn ESD within a low-volume tertiary centre within New Zealand via a prevalence-based approached. The majority of patients were able to have en bloc resection and a R0 resection. Our intent is that this data be used to help design a more formalised training process for learning ESD within a New Zealand setting.

The impact of COVID-19 restrictions on acute hospital presentations due to alcohol-related harm in Waitemata Auckland, New Zealand.

AIMS: New Zealand's public health response to the COVID-19 pandemic has largely been considered successful, although there have been concerns surrounding the potential harms of the lockdown restrictions enforced, including alteration of alcohol consumption. New Zealand utilised a four-tiered alert level system of lockdowns and restrictions, with Level 4 denoting strict lockdown. This study aimed to compare alcohol-related hospital presentations during these periods with corresponding calendar-matched dates from the preceding year. METHODS: We conducted a retrospective case-controlled analysis of all alcohol-related hospital presentations between 1 January 2019 to 2 December 2021 and compared COVID-19 restriction periods to corresponding calendar-matched pre-pandemic periods. RESULTS: A total of 3,722 and 3,479 alcohol-related acute hospital presentations occurred during the four COVID-19 restriction levels and corresponding control periods respectively. Alcohol-related presentations accounted for a greater proportion of all admissions during COVID-19 Alert Levels 3 and 1 than the respective control periods (both p⁢0.05), but not during Levels 4 and 2 (both p>0.30). Acute mental and behavioural disorders accounted for a greater proportion of alcohol-related presentations during Alert Levels 4 and 3 (both p≤0.02), although alcohol dependence was present in a lower proportion of presentations during Alert Levels 4, 3, and 2 (all p⁢0.01). There was no difference in acute medical conditions including hepatitis and pancreatitis during all alert levels (all p>0.05). CONCLUSION: Alcohol-related presentations were unchanged compared to matched control periods during the strictest level of lockdown, although acute mental and behavioural disorders accounted for a greater proportion of alcohol-related admissions during this period. New Zealand appears to have avoided the general trend of increased alcohol-related harms seen internationally during the COVID-19 pandemic and its lockdown restrictions.

Biomarkers in the early prediction of rescue therapy in acute severe colitis-a single-centre retrospective study.

Nil.

Endoscopic submucosal dissection: the first reported experience from a New Zealand centre.

AIM: Endoscopic submucosal dissection (ESD) is internationally accepted as a minimally invasive procedure to treat early gastrointestinal cancers endoscopically. Uptake of this procedure in the West is limited. No published data are available in New Zealand. We aimed to evaluate outcomes of this procedure at North Shore Hospital, Auckland. METHODS: Following an overseas fellowship training period, we prospectively collected clinical outcomes, complications and defined quality indicators for patients undergoing ESD referred following a multidisciplinary meeting. RESULTS: Between January 2020 until July 2021, 29 ESD procedures were performed in 27 patients, including 14 gastric, five oesophageal and 10 colorectal cases. The mean age was 72 (standard deviation (SD) 10.6). The majority of cases (62%) were done under general anaesthesia. The median lesion size resected was 30mm (interquartile range (IQR) 20-58mm). The pre-endoscopic diagnosis was accurate as confirmed on final histology in 93% of cases. Thirty-four percent of lesions were T1 adenocarcinoma and completely resected. The median total duration of the procedure was 90 minutes (IQR 55-180). 86% of lesions were resected en-bloc. R0 resection was achieved in 72% of cases. All cases with R0 resection were curative except one. Muscular defects without perforation were seen and clipped at the time of endoscopy in 34% of cases. Two perforations were identified and sealed at the time of endoscopy. There were no cases of delayed bleeding, perforation or mortality. CONCLUSION: These data demonstrate clinical success, efficacy and safety of ESD at our centre. A larger study, comparison with other centres and longer clinical follow-up is required to confirm findings and further improve outcomes.

Bleeding risk of oral anticoagulants in liver cirrhosis.

AIM: The safety of dabigatran is poorly studied in patients with liver cirrhosis and has rarely been compared to warfarin in terms of bleeding risks. METHOD: We undertook a retrospective cohort study across three tertiary centres in Auckland, New Zealand, between 2008 to 2020. Adults 18 years and over and those with a clinically confirmed diagnosis of cirrhosis were included. Data collected included demographic data and clinical characteristics, baseline medication and comorbidities. The primary outcome measure was the incidence of any bleeding event that resulted in hospital admission. RESULTS: Overall, 100 patients were included in this study. A total of 52 patients took warfarin, and 48 took dabigatran. Baseline characteristics for both groups were generally similar. The incidence rate of bleeds for patients taking warfarin was 14.4 per 100 person-years (95% CI, 8.8-23.5) compared to 9.1 per 100 person-years (95% CI, 4.5-18.1) for patients taking dabigatran. The incidence rate ratio comparing dabigatran to warfarin was 0.63 (95% CI, 0.23-1.60), p=0.25. CONCLUSION: Our study found that patients on dabigatran may have a lower bleeding risk than patients taking warfarin, but this was not statistically significant.

Artificial intelligence improves adenoma detection rate during colonoscopy.

BACKGROUND: Artificial intelligence-assisted colonoscopy (AIAC) has gained attention as a tool to assist with polyp detection during colonoscopy. Uncertainty remains as to the clinical benefit, given limited publications using different modules. METHOD: A single-centre retrospective study was performed at Waitemata Endoscopy, a private endoscopy centre in Auckland, New Zealand. An Olympus Endo-AID module was utilised for the first time by 13 experienced endoscopists. Outcomes from AIAC between 10 March 2021 to 23 April 2021 were compared to a subsequent non-AI conventional colonoscopy (CC) control group from 27/4/21 to 20/6/21. RESULTS: A total of 213 AIACs were compared with 213 CCs. Baseline patient age, gender, indication for procedure, bowel preparation scores and specialty of proceduralist (gastroenterologist or surgeon) were well matched (p>0.05). The withdrawal time was significantly longer in the AIAC group compared to CC controls (15 vs 13 minutes; p<0.001). The adenoma detection rate (ADR) was significantly higher in the AIAC group compared to CC group (47.9% vs 38.5%; odds ratio 1.59; 95% CI [1.05-2.41]; p=0.03). The overall polyp detection rate (PDR) was similar between groups (70% vs 70%; p=0.79). Analysis by polyp size, location and other histology was not significant between groups. CONCLUSION: AI-assisted colonoscopy significantly improved ADR compared with conventional colonoscopy. Further research is required to understand its utility and impact on long-term clinical outcomes.

The role of a novel self-expanding metal stent in variceal bleeding: a multicenter Australian and New Zealand experience.

Background and study aims Refractory variceal bleeding is associated with high mortality in patients with chronic liver disease. A fully-covered self-expanding metal stent (SEMS) has been reported to have excellent rates of technical success and initial bleeding control; however, studies to date are small and limited to Europe and Asia. Our aim was to evaluate the efficacy and safety of this SEMS for control of refractory variceal bleeding (VB). Patients and methods A retrospective analysis was undertaken of all patients who received the SX-ELLA Danis SEMS for management of VB at 9 tertiary centers across Australia and New Zealand. A total of 32 SEMS had been deployed in 30 patients (median age 53.3). Results Technical success of SEMS placement was achieved in 100 % of cases, resulting in immediate control of bleeding across 31 of 32 cases (96.9 %). Re-bleeding with SEMS in situ occurred in three of 32 cases (9.4 %). Mean SEMS in-dwelling time was 6.4 days. Delayed SEMS migration occurred in 6.3 % of cases. Interventional radiological therapy for management of varices within 6 weeks was performed in 12 of 30 patients (40 %). Death with SEMS in situ occurred in seven of 30 patients (23.3 %). Seven-day bleeding-related mortality was 16.7 %, 14-day mortality 23.3 %, and 6-week mortality 33.3 %. Three of 30 patients (10 %) received orthotopic liver transplantation following SEMS insertion, including two patients within 6 weeks. Conclusions SX-Danis Ella SEMS is highly effective for immediate control of refractory VB and bridging to definitive therapy because it has excellent technical success rates, appears to be relatively easy to use, and has low rates of serious adverse events.

Methods of tophus assessment in clinical trials of chronic gout: a systematic literature review and pictorial reference guide.

OBJECTIVE: To identify methods of tophus measurement for gout studies, summarise the properties of these methods and compile a detailed pictorial reference guide to demonstrate the methods. METHODS: A systematic search strategy for methods of tophus measurement was formulated. For each method, papers were assessed by two reviewers to summarise information according to the specific components of the Outcomes Measures in Rheumatology (OMERACT) filter: feasibility, truth and discrimination. Detailed images were obtained to construct the reference guide. RESULTS: Eight methods of tophus measurement were identified: counting the total number of tophi, physical measurement using tape measure, physical measurement using Vernier callipers, digital photography, ultrasonography (US), MRI, CT and dual energy CT. Feasibility aspects of the methods are well documented. Physical measurement techniques are more feasible than advanced imaging methods, but do not allow for assessment of intra-articular tophi or for data storage and central reading. The truth aspect of the filter has been documented for many methods, particularly Vernier callipers, US, MRI and CT. Reliability of most methods has been reported as very good or excellent. Sensitivity to change has been reported for all methods except MRI and CT. CONCLUSION: A variety of methods of tophus assessment have been described for use in clinical trials of chronic gout. Physical measurement techniques (particularly the Vernier calliper method) and US measurement of tophus size appear to meet most aspects of the OMERACT filter.

Quality of life after oesophageal stenting in patients with palliative oesophageal cancer.

AIM: Patients with incurable oesophageal cancer have poor outcomes, with disabling symptoms and a poor quality of life (QOL), which may be improved by oesophageal stenting. We aimed to measure change in symptoms related specifically to oesophageal cancer and overall QOL before and 30 days after stent insertion, to measure adverse effects and to define any patient factors that may be significant in predicting patients who may benefit most. METHODS: We prospectively enrolled patients in an observational study at Middlemore Hospital, New Zealand, and administered validated QOL- and symptomatology-based questionnaires before and 30 days after stent insertion. Additional patient-related demographics, procedural characteristics, adverse events and outcomes were collected. RESULTS: Between 31 March 2014 and 3 July 2020, 57 patients were initially recruited. Four patients withdrew from the study, and 13 patients died before 30 days. Forty patients (29 males; mean±SD age, 72±12 years) completed the study. A significant improvement was noted at one-month post stent insertion in the overall global QOL score (mean 35 to 46, p=0.01). The most significant score improvements were seen in dysphagia, trouble eating, trouble swallowing saliva and dry mouth (p<0.001). Physical, emotional, cognitive and social functioning did not change. Post-procedural adverse events occurred in 17 patients (43%). A poorer initial level of functioning was associated with reduced improvement in global QOL (p≤0.04). Patients followed-up died a mean of 2.8 months after insertion. CONCLUSION: In patients surviving longer than 30 days, there is significant improvement of overall QOL and dysphagia one-month post oesophageal stent insertion for malignant, palliative dysphagia. Multiple psychosocial facets were unchanged with this intervention. Stent-related adverse events were common.