Location, morphology and invasiveness of lateral spreading tumors in the colorectum differ between two large cohorts from an eastern and western country.

BACKGROUND AND STUDY AIMS: Data from Japanese series show that surface morphology of laterally spreading tumors (LST) in the colon identifies lesions with different incidence and pattern of submucosal invasion. Such data from western countries are scarce. We compared clinical and histological features of LST in a western country and an eastern country, with special interest on mucosal invasiveness of LST, and investigated the effect of clinical factors on invasiveness in both countries. PATIENTS AND METHODS: Patients with LST lesions ≥20mm were included from a multicenter prospective registry in Spain and from a retrospective registry from the National Cancer Center Hospital East, Japan. The primary outcome was the presence of submucosal invasion in LST. The secondary outcome was the presence of high-risk histology, defined as high-grade dysplasia or submucosal invasion. RESULTS: We evaluated 1102 patients in Spain and 663 in Japan. Morphological and histological characteristics differed. The prevalence of submucosal invasion in Japan was six-fold the prevalence in Spain (Prevalence Ratio PR=5.66; 95%CI: 3.96, 8.08), and the prevalence of high-risk histology was 1.5 higher (PR=1.44; 95%CI: 1.31, 1.58). Compared to the granular homogeneous type and adjusted by clinical features, granular mixed, flat elevated, and pseudo-depressed types were associated with higher odds of submucosal invasion in Japan, whereas only the pseudo-depressed type showed higher risk in Spain. Regarding high-risk histology, both granular mixed and pseudo-depressed were associated with higher odds in Japan, compared with only the granular mixed type in Spain. CONCLUSION: This study reveals differences in location, morphology and invasiveness of LST in an eastern and a western cohort.

Clinical validation of risk scoring systems to predict risk of delayed bleeding after EMR of large colorectal lesions.

BACKGROUND AND AIMS: The Endoscopic Resection Group of the Spanish Society of Endoscopy (GSEED-RE) model and the Australian Colonic Endoscopic Resection (ACER) model were proposed to predict delayed bleeding (DB) after EMR of large superficial colorectal lesions, but neither has been validated. We validated and updated these models. METHODS: A multicenter cohort study was performed in patients with nonpedunculated lesions ≥20 mm removed by EMR. We assessed the discrimination and calibration of the GSEED-RE and ACER models. Difficulty performing EMR was subjectively categorized as low, medium, or high. We created a new model, including factors associated with DB in 3 cohort studies. RESULTS: DB occurred in 45 of 1034 EMRs (4.5%); it was associated with proximal location (odds ratio [OR], 2.84; 95% confidence interval [CI], 1.31-6.16), antiplatelet agents (OR, 2.51; 95% CI, .99-6.34) or anticoagulants (OR, 4.54; 95% CI, 2.14-9.63), difficulty of EMR (OR, 3.23; 95% CI, 1.41-7.40), and comorbidity (OR, 2.11; 95% CI, .99-4.47). The GSEED-RE and ACER models did not accurately predict DB. Re-estimation and recalibration yielded acceptable results (GSEED-RE area under the curve [AUC], .64 [95% CI, .54-.74]; ACER AUC, .65 [95% CI, .57-.73]). We used lesion size, proximal location, comorbidity, and antiplatelet or anticoagulant therapy to generate a new model, the GSEED-RE2, which achieved higher AUC values (.69-.73; 95% CI, .59-.80) and exhibited lower susceptibility to changes among datasets. CONCLUSIONS: The updated GSEED-RE and ACER models achieved acceptable prediction levels of DB. The GSEED-RE2 model may achieve better prediction results and could be used to guide the management of patients after validation by other external groups. (Clinical trial registration number: NCT03050333.).

Short and long-term outcomes of underwater EMR compared to the traditional procedure in the real clinical practice.

BACKGROUND AND AIMS: underwater endoscopic mucosal resection (U-EMR) has been recently described as an alternative to endoscopic mucosal resection (EMR) for flat colorectal polyps. However, the real applications remain unclear due to the lack of comparative studies. METHODS: a multi-centric prospective study was performed from November 2016 to December 2017. All lesions larger than 15 mm that were resected with both techniques were included in the study. The samples were matched using the size, morphology, site and access (SMSA) score as a reference. The efficacy, efficiency and adverse events rates were compared. RESULTS: a total of 162 resections were collected (112 EMR and 50 U-EMR) with an average size of 25 mm. U-EMR achieved better results for the en bloc resection rate (49 vs 62%; p = 0.08) and there were no cases of an incomplete resection (10.7 vs 0%; p = 0.01). U-EMR was faster than EMR and there were no differences in the adverse events rate. Furthermore, U-EMR tended to achieve better results in terms of recurrence. Performing the resection in emersion appeared to prevent the cautery artefact, especially in sessile serrated adenomas. CONCLUSION: in the real clinical practice, U-EMR and EMR are equivalent in terms of efficacy and safety. Furthermore, U-EMR may be a feasible approach to prevent cautery artefact, allowing an accurate pathologic assessment.

Clinical guidelines for endoscopic mucosal resection of non-pedunculated colorectal lesions.

This document summarizes the contents of the Clinical Guidelines for the Endoscopic Mucosal Resection of Non-Pedunculated Colorectal Lesions that was developed by the working group of the Spanish Society of Digestive Endoscopy (GSEED of Endoscopic Resection). This document presents recommendations for the endoscopic management of superficial colorectal neoplastic lesions.

Clinical guidelines for endoscopic mucosal resection of non-pedunculated colorectal lesions. / Guía clínica para la resección mucosa endoscópica de lesiones colorrectales no pediculadas.

This document summarizes the contents of the Clinical Guidelines for the Endoscopic Mucosal Resection of Non-Pedunculated Colorectal Lesions that was developed by the working group of the Spanish Society of Digestive Endoscopy (GSEED of Endoscopic Resection). This document presents recommendations for the endoscopic management of superficial colorectal neoplastic lesions.

A Scoring System to Determine Risk of Delayed Bleeding After Endoscopic Mucosal Resection of Large Colorectal Lesions.

BACKGROUND & AIMS: After endoscopic mucosal resection (EMR) of colorectal lesions, delayed bleeding is the most common serious complication, but there are no guidelines for its prevention. We aimed to identify risk factors associated with delayed bleeding that required medical attention after discharge until day 15 and develop a scoring system to identify patients at risk. METHODS: We performed a prospective study of 1214 consecutive patients with nonpedunculated colorectal lesions 20 mm or larger treated by EMR (n = 1255) at 23 hospitals in Spain, from February 2013 through February 2015. Patients were examined 15 days after the procedure, and medical data were collected. We used the data to create a delayed bleeding scoring system, and assigned a weight to each risk factor based on the ß parameter from multivariate logistic regression analysis. Patients were classified as being at low, average, or high risk for delayed bleeding. RESULTS: Delayed bleeding occurred in 46 cases (3.7%, 95% confidence interval, 2.7%-4.9%). In multivariate analysis, factors associated with delayed bleeding included age ≥75 years (odds ratio [OR], 2.36; P < .01), American Society of Anesthesiologist classification scores of III or IV (OR, 1.90; P ≤ .05), aspirin use during EMR (OR, 3.16; P < .05), right-sided lesions (OR, 4.86; P < .01), lesion size ≥40 mm (OR, 1.91; P ≤ .05), and a mucosal gap not closed by hemoclips (OR, 3.63; P ≤ .01). We developed a risk scoring system based on these 6 variables that assigned patients to the low-risk (score, 0-3), average-risk (score, 4-7), or high-risk (score, 8-10) categories with a receiver operating characteristic curve of 0.77 (95% confidence interval, 0.70-0.83). In these groups, the probabilities of delayed bleeding were 0.6%, 5.5%, and 40%, respectively. CONCLUSIONS: The risk of delayed bleeding after EMR of large colorectal lesions is 3.7%. We developed a risk scoring system based on 6 factors that determined the risk for delayed bleeding (receiver operating characteristic curve, 0.77). The factors most strongly associated with delayed bleeding were right-sided lesions, aspirin use, and mucosal defects not closed by hemoclips. Patients considered to be high risk (score, 8-10) had a 40% probability of delayed bleeding.

Actinomyces infection as a complication of a post-radiotherapy rectal ulcer.

INTRODUCTION: Pelvic radiotherapy is associated with early and late local complication. Actinomyces bacterium is part of the saprophyte flora, although some infection underlying factors are known , the pathophysiology of the disease is still unexplained. Frequently it is involved in oral, gastrointestinal and respiratory infections. CASE REPORT: We present the description of a clinical case supported with images. So that we have developed a bibliographical research in Pubmed data base including the following key words: Ulcer, rectum, brachitherapy and Actinomyces. The most recent original articles published in the last teen years, related with the pathology observed in the patient of the case, were selected. DISCUSSION: Brachitherapy over pelvic beds ( prostate, cervix and uterus) could be associated with digestive complications specially in the rectum. Those complications might oscillate from mild inflammatory changes in the mucosa to serious damages as ulcers and lack of tissue. This situation increase the risk of opportunistic infections which could endanger the clinical improve of our patients. We suggest to remember those germen in the diagnosis process in other to achieve an early diagnosis and to use a targeted treatment.

Effectiveness of serological markers of eosinophil activity in monitoring eosinophilic esophagitis.

BACKGROUND: it is necessary to find serological markers accessible in clinical practice to prevent the need to perform repeated endoscopies. OBJECTIVE: to assess the efficacy of eosinophil activity markers in monitoring eosinophilic esophagitis (EoE). MATERIAL AND METHODS: thirty patients were included prospectively, all under dietary treatment -diets excluding 6 foods, and allergy test based diet (skin prick test and specific IgE). The variables assessed were demographic parameters, eosinophil cationic protein (ECP) levels (µg/mL), total IgE (KU/L), peripheral blood eosinophils (PBE) (U/mm³), and the maximum peak of eosinophils/hpf in esophageal biopsies. The variation found between these figures was assessed in line with response to dietary treatment. RESULTS: thirty patients (66.7% males; mean age 33.43 years) were included in the study, 22 responders and 8 non-responders. Ninety percent presented a personal history of atopy. No significant decrease was detected in serum total IgE and ECP after diet in responder and nonresponders. However, the PBE decreased significantly in responders but not in nonresponders, PBE in responders (pre-diet. 397.27 vs. post-diet 276.81, p = 0.024) and non-responders PBE (pre-diet. 460 vs. post-diet 317.5, p = 0.23). CONCLUSION: serum total IgE and ECP do not act as markers for EoE activity. However PBE may play a role in this regard, bearing in mind that this parameter may be influenced by concomitant atopic conditions.

Cavitating mesenteric lymph node syndrome: a rare complication of celiac disease.

Among the many complications of celiac disease, mesenteric lymph node syndrome cavitated is considered one of the rarest, there is few case series published in the literature. The etiology and pathophysiology are unknown but because of its high mortality rate, estimated to be around 50%, it should recognize at an early stage in order to institute appropriate therapy as soon as possible.

Detection and characterization of colorectal polyps using high-definition white light and i-Scan: Evidence-based consensus recommendations using a modified Delphi process.

BACKGROUND: i-Scan is an image enhancement modality, which provides enhanced views of mucosal structures and vascular patterns. METHODS: A modified Delphi process was used to develop a series of evidence-based statements on the role of high-definition white light (HDWL) and i-Scan for the detection and diagnosis of colorectal neoplasms. Each statement was voted to achieve consensus (i.e. >80% agreement). RESULTS: Seven proposed statements achieved consensus: (1) HDWL is recommended rather than standard definition (SD) for detection and diagnosis of colorectal neoplasms; (2) HDWL colonoscopy with i-Scan improves polyp and adenoma detection rates when compared with SD colonoscopy; (3) HDWL + i-Scan is superior to HDWL alone for the optical diagnosis of colorectal neoplasms; (4) HDWL + i-Scan in expert hands meets American Society for Gastrointestinal Endoscopy (ASGE) in the Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) standards for optical diagnosis of diminutive neoplasms; (5) HDWL + i-Scan in non-expert hands does not meet ASGE PIVI standards for optical diagnosis of diminutive neoplasms; (6) optical diagnosis of polyps with i-Scan has a learning curve and needs systematic training; and (7) the performance of i-Scan for the in vivo diagnosis of colorectal neoplasms is similar to Narrow Band Imaging (NBI) and Fuji Intelligent Chromo Endoscopy (FICE). CONCLUSIONS: Seven proposed statements on the use of HDWL and i-Scan for the detection and diagnosis of colorectal neoplasms achieved consensus.

Endoscopic Ultrasound for the Detection of Left Atrial Appendage Thrombus: A Useful Technique in Patients with Transesophageal Echocardiography Contraindication.

Endoscopic ultrasound is a diagnostic and therapeutic technique used in specialized centers for patients that have undergone digestive procedures. This technique enables highly precise real-time imaging of the digestive tract wall and surrounding organs. Endoscopic ultrasound is also useful in patients with cardiovascular diseases such as atrial fibrillation. In patients with contraindication for transesophageal echocardiography due to high risk of esophageal bleeding or complications that may require immediate intervention, endoscopic ultrasound may be a safer option for visualizing atrial chambers to rule out the presence of left atrial appendage thrombi before cardioversion.

Automated image analysis in the study of lymphocyte subpopulation in eosinophilic oesophagitis.

BACKGROUND: Eosinophilic oesophagitis (EoE) is characterized by the presence of eosinophils in oesophageal mucosa. Other inflammatory cells, mainly lymphocytes, dendritic cells, and mast cells may also play an important role in this disease. The aim of this study is to compare the inflammatory pattern of the mucosa between EoE and gastro-oesophageal reflux disease (GERD), using automatic image analysis in digital slides, and to assess treatment response after elimination diet and food challenge test. METHODS: From 2010 to 2013, 35 oesophageal biopsies from EoE and GERD patients were randomly selected. In six EoE biopsies, patients had been treated with selective food exclusion diet. Immunohistochemical study with CD3, CD20, CD4, and CD8 for lymphocyte populations, CD1a for dendritic cells, and CD117/c-kit for mast cells was performed. Slides were scanned using Leica Aperio Scanscope XT with 40× magnification. Immunohistochemical expression was quantified in 245 immunohistochemistry digital slides with Leica Aperio positive pixel count algorithm using two different approaches: whole slide analysis versus selection of a 2 mm2 hot spot area. RESULTS: Average eosinophil cell count was significantly higher (p < 0.001) in the first biopsy of EoE patients before treatment (30.75 eosinophils per high power field - HPF) than in GERD patients (0.85 eosinophils/HPF) or in EoE patients after treatment with elimination diet (1.60 eosinophils/HPF). In the immunohistochemical study, manual count and automatic image analysis showed a significant increase in the number of CD3 and CD8 cells in EoE patients, compared with GERD patients. However, the increase of CD117/c-kit was only statistically significant when manual counting procedures were used. CD20 positive cell count also showed a non-statistically significant tendency to reduce after elimination diet treatment. CONCLUSIONS: Positive pixel count algorithm can be a useful tool to quantify the immunohistochemical expression of inflammatory cells in the diagnosis and follow up of eosinophilic oesophagitis.

Accuracy of liquid cytology in the diagnosis and monitoring of eosinophilic oesophagitis.

BACKGROUND: Oesophagoscopy with biopsy is considered the gold standard for diagnosing and monitoring eosinophilic oesophagitis (EoE). Therefore is important to discover less-invasive diagnostic methods. METHODS: Cytology specimens were obtained in patients with active EoE (AEoE) (≥15 eos/hpf) and EoE in remission (EoER) (<15 eos/hpf). The samples were assessed by two independent pathologists and were compared with biopsy samples. EoE cytology specimens were compared with specimens obtained from patients with GERD. RESULTS: Specimens of 36 patients (69.4% male, mean age 30.88 years) were included. AEoE (17, 47.2%), EoER (11, 30.5%) and GERD (22.2%). eos/hpf in cytology (AEoE 9.23 vs. EoER 1.54 vs. GERD 2, p = 0.01). Linear correlation between eos/hpf average biopsy and cytology eos/hpf: r = 0.57, p < 0.001. For diagnosis of EoE ≥3 eos/hpf in cytology obtained a sensitivity of 70%, specificity 81%, PPV 86% and NPV 60% (AUC = 0.81, p = 0.01). For detection of AEoE, ≥3 eos/hpf in LBC obtained a sensitivity of 70%, specificity 82%, PPV 81% and NPV 66% (AUC = 0.87, p = 0.001). CONCLUSIONS: LBC in oesophageal aspirate seems to be effective for the diagnosis and monitoring activity in EoE. These results support the usefulness of non-invasive methods for the diagnosis and monitoring of EoE.