Outcome of EMR as an alternative to surgery in patients with complex colon polyps.

BACKGROUND AND AIMS: Patients with complex colon polyps were traditionally referred for surgery to avoid adverse events associated with endoscopic resection. Recent advances in endoscopic imaging as well as endoscopic hemostasis and clip closure allow for the use of EMR as an alternative to surgery for such lesions. To determine the outcome of treatment of complex colon polyps with EMR as an alternative to surgery, we conducted a retrospective observational study. METHODS: Two hundred three patients with complex colon polyps were referred to an EMR center as an alternative to surgery. Patients underwent a protocol-driven EMR. The primary endpoint was the complete resection rate. Secondary endpoints were safety, residual adenoma rate, and incidence of missed synchronous polyps. RESULTS: EMR was performed in 155 patients and was deferred in 48 patients who were referred to surgery. EMR specimens revealed benign polyps in 149 and cancer in 6 patients. EMR adverse events occurred in 7 patients, requiring hospitalization in 5 of them. None of the patients died as a result of their adverse events. Surveillance colonoscopy at 4 to 6 months after resection of a benign lesion in 137 patients revealed residual adenoma at the scar site in 6 patients and additional synchronous precancerous lesions in 117 patients that were not removed by the referring endoscopist. None underwent surgery for failure of EMR. The overall precancerous lesion burden was 2.83 per patient, the adenoma burden was 2.13 per patient, and the serrated polyp burden was .69 per patient. CONCLUSIONS: EMR can be used instead of surgery for complex colon polyps in 75% of patients with few adverse events and few residual adenomas at resection sites. In addition, careful repeat examination of the entire colon for synchronous lesions overlooked by the referring endoscopist is required for most patients. ( CLINICAL TRIAL REGISTRATION NUMBER: NCT01827241.).

Natural language processing as an alternative to manual reporting of colonoscopy quality metrics.

BACKGROUND AND AIMS: The adenoma detection rate (ADR) is a quality metric tied to interval colon cancer occurrence. However, manual extraction of data to calculate and track the ADR in clinical practice is labor-intensive. To overcome this difficulty, we developed a natural language processing (NLP) method to identify adenomas and sessile serrated adenomas (SSAs) in patients undergoing their first screening colonoscopy. We compared the NLP-generated results with that of manual data extraction to test the accuracy of NLP and report on colonoscopy quality metrics using NLP. METHODS: Identification of screening colonoscopies using NLP was compared with that using the manual method for 12,748 patients who underwent colonoscopies from July 2010 to February 2013. Also, identification of adenomas and SSAs using NLP was compared with that using the manual method with 2259 matched patient records. Colonoscopy ADRs using these methods were generated for each physician. RESULTS: NLP correctly identified 91.3% of the screening examinations, whereas the manual method identified 87.8% of them. Both the manual method and NLP correctly identified examinations of patients with adenomas and SSAs in the matched records almost perfectly. Both NLP and the manual method produced comparable values for ADRs for each endoscopist and for the group as a whole. CONCLUSIONS: NLP can correctly identify screening colonoscopies, accurately identify adenomas and SSAs in a pathology database, and provide real-time quality metrics for colonoscopy.

Endoscopic management of Barrett's esophagus with high-grade dysplasia and early-stage esophageal adenocarcinoma.

Several endoscopic procedures have been recently developed for the treatment of Barrett's esophagus and early esophageal cancer, including endoscopic resection, radiofrequency ablation, and cryoablation. This review article discusses ideal candidates for endoscopic therapies, current treatment modalities, clinical and safety outcomes, and specific management recommendations.

Optimum palliation of inoperable hilar cholangiocarcinoma: comparative assessment of the efficacy of plastic and self-expanding metal stents.

BACKGROUND: Endoscopic retrograde biliary drainage (ERBD) with plastic or self-expanding metal stents (SEMS) is often performed for palliative care for cholangiocarcinoma. OBJECTIVE: The objective was to compare the clinical effectiveness, including stent patency, complication rate, and need for salvage percutaneous transhepatic biliary drainage, of SEMS and plastic stents. METHODS: A total of 100 patients with inoperable cholangiocarcinoma were identified from an endoscopic database from 1/1/01 to 9/30/06 at a tertiary cancer hospital and their clinical history was retrospectively reviewed. All patients were followed to death, re-intervention, or for at least one year. Stent patency and patient survival were estimated by Kaplan-Meier analysis, supplemented by the log-rank test for comparisons between groups. RESULTS: Forty-eight patients had SEMS placed and 52 patients had plastic stents placed. ERBD was successful in 46 (95.8%) in the SEMS group and 49 (94.2%) in the plastic group (P = 0.67). Median patency times were 1.86 months in the plastic group and 5.56 months in the SEMS group (P < 0.0001). A mean of 1.53 and 4.60 re-interventions were performed in the SEMS and plastic groups, respectively (P < 0.05). Complications occurred in 4/48 (8.3%) in the SEMS group and 4/52 (7.7%) in the plastic group (P = 0.79). Median survival was 9.08 and 8.22 months in the SEMS and plastic stent groups, respectively (P = 0.50). CONCLUSION: Metallic stent patency was superior to that of plastic stents in all Bismuth-Corlette classifications of hilar cholangiocarcinoma with similar complication rates. SEMS seem to be cost-effective and, when feasible, should be considered as an initial intervention in patients with inoperable hilar cholangiocarcinoma.

Photodynamic therapy.

Photodynamic therapy (PDT) is a photochemical process that uses a photosensitizer drug activated by laser light to produce mucosal ablation. Porfimer sodium PDT has proved long-term efficacy and durability in the treatment of Barrett's esophagus and high-grade dysplasia and early esophageal adenocarcinoma. Its use has been limited by serious side effects including prolonged cutaneous photosensitivity and stricture formation. Other photosensitizers with a better safety profile have been used mostly in Europe with limited experience. The future of PDT lies on a better understanding of dosimetry, tissue properties, and host genetic factors.

Neutropenic enterocolitis: current issues in diagnosis and management.

Neutropenic enterocolitis or typhlitis (from the Greek word typhlon, meaning cecum) is a clinical syndrome that occurs in the setting of disease or chemotherapy-induced neutropenia. The disease is characterized by an inflammatory process involving colon and/or small bowel, and it can result in ischemia, necrosis, bacteremia, hemorrhage, and perforation. The classic clinical features include fever and abdominal pain. The diagnosis is supported by the findings of bowel wall thickening on ultrasonography or CT imaging. The management of neutropenic enterocolitis is controversial. Neither prospective nor high-quality retrospective studies concerning medical or surgical therapies are available. Most authors will recommend initial conservative management with bowel rest, intravenous fluids, total parenteral nutrition, broad-spectrum antibiotics and normalization of neutrophil counts. Surgical intervention is recommended in the setting of obstruction, perforation, persistent gastrointestinal bleeding despite correction of thrombocytopenia and coagulopathy, and clinical deterioration.

Neutropenic enterocolitis.

Neutropenic enterocolitis is a life-threatening gastrointestinal (GI) complication of chemotherapy most often associated with leukemia or lymphoma. Early recognition and treatment are essential for survival. The management of neutropenic enterocolitis is controversial. Neither prospective nor high-quality retrospective studies concerning medical or surgical therapies are available. Treatment approaches have been derived mostly from small case studies and retrospective reports. Therefore, a uniform management strategy cannot be recommended. The best strategy appears to be an individualized approach to each case given the wide spectrum of presentation. There is general agreement that early management should be conservative and should consist of bowel rest, intravenous fluid administration, total parenteral nutrition, broad-spectrum antibiotics, and normalization of neutrophil counts. Surgical intervention is warranted in the setting of perforation, obstruction, clinical deterioration suggestive of uncontrolled sepsis, and persistent GI bleeding despite correction of cytopenias and coagulopathy.

Neutropenic enterocolitis.

PURPOSE OF REVIEW: This review will cover the recent literature pertaining to the pathogenesis, diagnosis, and management of patients with neutropenic enterocolitis. RECENT FINDINGS: Neutropenic enterocolitis, also referred to as typhlitis, is a life-threatening gastrointestinal complication of chemotherapy, most often associated with leukemia or lymphoma. Recently, a larger number of reports have been published of individuals presenting with this syndrome after being treated with newer chemotherapeutic agents for solid tumors such as non-small cell lung, ovarian, and peritoneal cancer, as well as following autologous stem cell transplantation. Recent studies have also better characterized computed tomographic and ultrasonographic features of this entity that can help differentiate neutropenic enterocolitis from other gastrointestinal complications. A newly published systematic analysis of the literature, which included 145 articles, defines appropriate diagnostic criteria and treatment recommendations. SUMMARY: Neutropenic enterocolitis is a serious, potentially lethal complication of anticancer therapy. The studies discussed in this review will help the practitioner make an appropriate, early diagnosis and implement a therapeutic program that would improve the outcome of these patients.