Characteristics of metachronous colorectal adenomas found during long-term follow-up: analysis of four subsequent generations of adenoma recurrence.

OBJECTIVE: Because of the high recurrence rates of colorectal adenomas, regular surveillance by colonoscopy has been recommended, but there is still a dearth of information on the long-term results of follow-up colonoscopy after polypectomy. The aims of this study were to determine the differences between initial adenomas and metachronous lesions, to evaluate the effect of long-term surveillance and to describe the hypothetical origin of the colorectal adenoma-carcinoma sequence. MATERIAL AND METHODS: Between 1978 and 2003 a total of 1091 patients undergoing periodic surveillance examinations were prospectively documented at the Erlangen Registry of Colorectal Polyps. Differences between initial and metachronous lesions found during long-term follow-up were studied. Statistical analysis using chi(2) testing of adenoma characteristics found in four subsequent recurrence periods was carried out, and the relative risk (RR) for the development of metachronous adenomas of advanced pathology was calculated. RESULTS: In comparison with the initial findings, metachronous adenomas are generally significantly smaller lesions (p<0.00001), usually tubular in shape (p<0.00001) and bearing high-grade dysplasia less often (p<0.00001) and are usually located in the right colon (p<0.00001). These differences are found between the initial and four subsequent generations of metachronous adenomas. The number of synchronous adenomas is reduced only in the first recurrence (p<0.001); in the further generations equal proportions of multiplicity are found, as in the baseline examination. Patients with adenomas of advanced pathology, i.e. large, tubulovillous or villous adenomas at baseline, have a significantly higher risk for large (RR 2.73; 95% CI 1.77-4.20), tubulovillous or villous (RR 1.55; 95% CI 1.06-2.25) or multiple (RR 2.45; 95% CI 1.83-3.29) metachronous adenomas at the first recurrence. CONCLUSIONS: Metachronous adenomas show the uniform characteristics of being small tubular lesions rarely bearing high-grade dysplasia, usually located in the right colon. Thus regular follow-up colonoscopy can provide sufficient colorectal carcinoma prevention.

Low-molecular-weight heparin does not prevent acute post-ERCP pancreatitis.

BACKGROUND: Studies suggest that heparin has anti-inflammatory effects that could prevent acute post-ERCP pancreatitis. The aim of this investigator-initiated, prospective, randomized, double-blind, multicenter study was to determine whether low-molecular-weight heparin can prevent acute post-ERCP pancreatitis. METHODS: Patients at increased risk for acute post-ERCP pancreatitis based on assessment of known risk factors were randomized to receive low-molecular-weight heparin (Certoparin 3000 IU subcutaneously) or placebo (saline solution 0.3 mL subcutaneously) the day before ERCP. The drug was given 2 hours before and 22 hours after ERCP. Documentation and follow-up included patient history, risk factors for acute post-ERCP pancreatitis, procedure-related data, assessment of pain (visual analogue scale, need for pain medication), laboratory findings before and after ERCP (0, 4, and 24 hours), as well as post-ERCP complications. The two-sided Fisher exact test was used for statistical comparison, and a p value < or =0.05 was considered significant. RESULTS: A total of 458 patients were enrolled in the study. Data from 10 patients could not be evaluated, leaving 221 patients in the low-molecular-weight heparin group and 227 in the placebo group (total 448 patients; 135 men, 313 women; mean age 58 [15] years). Low-molecular-weight heparin and placebo groups were comparable with regard to risk factors for acute post-ERCP pancreatitis (gender distribution, age <65 years, history of pancreatitis, pancreas divisum, disorders of sphincter of Oddi) and procedure-related data (difficult cannulation, diagnostic or therapeutic ERCP, needle-knife papillotomy, endoscopic sphincterotomy, biliary or pancreatic procedure, pancreatic contrast injection, success and final diagnosis of ERCP). Acute post-ERCP pancreatitis occurred in 8.5% (38/448), with one death resulting from severe pancreatitis. Low-molecular-weight heparin offered no benefit compared with placebo based on the frequency of acute post-ERCP pancreatitis (low-molecular-weight heparin, 18/221 vs. placebo, 20/227; p=0.87) and the severity of acute post-ERCP pancreatitis (low-molecular-weight heparin, 14 mild, 3 moderate, one severe; placebo, 18 mild, two moderate, 0 severe). The 24-hour serum amylase values and 24-hour pain scores did not differ significantly between the low-molecular-weight heparin group and the placebo group. Bleeding complications occurred in two patients, both in the low-molecular-weight heparin group (one mild, one moderate). CONCLUSIONS: Prophylactic subcutaneous administration of low-molecular-weight heparin does not prevent acute post-ERCP pancreatitis.

Endoscopic placement of nasojejunal tubes: a randomized, controlled, prospective trial comparing suitability and technical success for two different tubes.

BACKGROUND: Jejunal feeding is an attractive means for delivering nutrients to critically ill patients. Nasojejunal tubes may have different advantages and disadvantages that may have important clinical implications. METHODS: To compare the suitability of 2 different nasojejunal feeding tubes (Tube A, Dobbhoff; Tube B, Freka-Trelumina) for use by endoscopists and nursing staff, a randomized, controlled, prospective trial was performed in 60 patients. The primary end point was time required for tube placement. Secondary end points were successful placement and nursing problems encountered during clinical use. Results of upper endoscopy were also recorded. RESULTS: Placement took significantly longer with Tube A than Tube B (95% CI for median [11.5, 20.0] minutes vs. [5.5, 7.5] minutes; p < 0.001), and was less successful (73.3% vs. 90%; p = 0.18). Nursing problems occurred significantly more often with Tube A compared with Tube B (11 vs. 1; p < 0.001). Tube B stayed in place significantly longer than Tube A (37 days vs. 21 days; p = 0.034). In 45% of the cases, upper endoscopy provided a diagnosis of potential therapeutic relevance. CONCLUSIONS: Selection of a nasojejunal tube for endoscopic placement has significant implications with respect to time required for placement, duration of tube usage and the practicability for nursing staff. Diagnostic upper endoscopy performed concomitantly often reveals findings of clinical importance.

Complications of endoscopic sphincterotomy: can heparin prevent acute pancreatitis after ERCP?

BACKGROUND: An exploratory analysis of a prospective study of risk factors for acute pancreatitis after ERCP combined with endoscopic sphincterotomy showed that the frequency of acute pancreatitis was lower in patients who received heparin compared with patients not treated with heparin. The study was continued to further analyze the effect of heparin on the frequency of acute pancreatitis. METHODS: Potential risk factors for acute pancreatitis and outcomes were evaluated prospectively for all ERCP procedures with endoscopic sphincterotomy performed between September 1994 and December 1998. The results were analyzed by univariate and multivariate methods to determine risk factors for complications. Heparin was administered to 32.9% of the patients (heparin group [HEP group], n = 268) for various clinical reasons (low-molecular-weight heparin, n = 208, unfractionated heparin n = 60). A group of 547 patients who did not receive heparin served as control patients (CON group). RESULTS: Eight hundred fifteen patients underwent ERCP with endoscopic sphincterotomy; acute pancreatitis occurred in 6.4% (n = 52). The frequency of acute pancreatitis was significantly lower in the HEP group versus the CON group in the final multivariate model, which included significant risk factors for acute pancreatitis (HEP group: 3.4%, 9/268 vs. CON group: 7.9%, 43/547; p = 0.005). HEP did not increase the risk of hemorrhage (HEP group: 1.1%, 3/268, 2 severe, none fatal vs. CON group: 2.0%, 11/547, 3 severe, 2 fatal). HEP (p = 0.005; OR 0.3: 95% CI [0.16, 0.73]) and the number of risk factors present (p = 0.0001; OR 2.5: 95% CI [1.80, 3.50]) influenced the frequency of acute pancreatitis independently. CONCLUSIONS: Heparin was significantly associated with an extremely low frequency of post-ERCP pancreatitis without increasing the risk of hemorrhage after endoscopic sphincterotomy. Because this effect could not be attributed to other known or suspected confounders, our conclusion was that heparin administration before ERCP reduces the risk of pancreatitis.