WHICH LESIONS ARE AT HIGHER RISK OF DEVELOPING COLORECTAL CARCINOMAS: SUPERFICIALLY ELEVATED SERRATED LESIONS OR DEPRESSED LESIONS?

BACKGROUND: There are lesions that are still being missed in colonoscopy. Many of those could be superficially elevated serrated lesions or depressed ones. AIMS: The aim of this study was to compare the histopathological characteristics of these lesions and their risks for submucosal carcinoma. METHODS: This is a retrospective, cross-sectional, and observational study comparing 217 superficially elevated serrated lesions larger than 5 mm resected by colonoscopies (G1) with 558 depressed lesions (G2). RESULTS: In G1, 217 lesions were found in 12,653 (1.7%) colonoscopies; in G2, 558 lesions were found in 36,174 (1.5%) colonoscopies. In G1, 63.4% were women and in G2, there was no gender predominance. The average size of G1 was 16.2 mm and G2 was 9.2 mm (p<0.001). G1 predominated on the proximal colon and G2 on the distal and rectum (p<0.001). In G1, there were 214 (98.6%) low-grade intramucosal neoplasia and 3 (1.4%) high-grade intramucosal neoplasia. Excluding 126 hyperplastic polyps and considering 91 sessile serrated adenomas in G1, we observed 88 (96.7%) low-grade intramucosal neoplasia and 3 (3.3%) high-grade intramucosal neoplasia; in G2, we observed 417 (74.7%) low-grade intramucosal neoplasia, 113 (20.3%) high-grade intramucosal neoplasia, and 28 (5.0%) submucosal adenocarcinomas (p<0.001). CONCLUSION: Depressed lesions significantly had more high-grade intramucosal neoplasia and more invasive carcinomas in the submucosal layer than superficially elevated serrated lesions and more than superficially elevated sessile serrated adenomas.

Which lesions are at higher risk of developing colorectal carcinomas: superficially elevated serrated lesions or depressed lesions? / QUAIS LESÕES APRESENTAM MAIOR RISCO DE EVOLUÇÃO PARA CARCINOMAS COLORRETAIS: AS SERRILHADAS SUPERFICIALMENTE ELEVADAS OU AS DEPRIMIDAS?

Background: There are lesions that are still being missed in colonoscopy. Many of those could be superficially elevated serrated lesions or depressed ones. Aim: Compare the histopathological characteristics of these lesions and their risks for submucosal carcinoma. Methods: Retrospective, cross-sectional and observational study comparing 217 superficially elevated serrated lesions larger than 5 mm resected by colonoscopies (G1) with 558 depressed lesions (G2). Results: In G1, 217 lesions were found in 12653 colonoscopies (1,7%); in G2, 558 lesions in 36174 colonoscopies (1.5%). In G1 there were 63.4% of women and in G2 no gender predominance. Average size was G1 with 16.2 mm and G2 with 9.2 mm (p<0.001). G1 predominated on the proximal colon and G2 on the distal and rectum (p<0.001). In G1 there were 214 low-grade intramucosal neoplasia (98,6%) and three high grade intramucosal neoplasia (1,4%). Excluding 126 hyperplastic polyps and considering 91 sessile serrated adenomas in G1, was observed 88 (96.7%) with low-grade intramucosal neoplasia and three (3.3%) high-grade intramucosal neoplasia; in G2, 417 low-grade intramucosal neoplasia (74,7%), 113 high-grade intramucosal neoplasia (20,3%) and 28 (5,0%) submucosal adenocarcinomas (p<0.001). Conclusion: Depressed lesions significantly had more high-grade intramucosal neoplasia and more invasive carcinomas for the submucosal layer than superficially elevated serrated lesions and more than superficially elevated sessile serrated adenomas.

Racional: Há ainda lesões que podem ser perdidas nas colonoscopias. Muitas delas poderiam ser serrilhadas superficialmente elevadas ou deprimidas. Objetivo: Comparar as características histopatológicas destas lesões e seus riscos para carcinoma invasivo para a submucosa. Método: Estudo retrospectivo, transversal, observacional comparando 217 lesões serrilhadas superficialmente elevadas com mais de 5 mm e ressecadas por colonoscopias (G1) com 558 lesões deprimidas (G2). Resultados: As 217 lesões do G1 foram encontradas em 12653 colonoscopias (1,7%) enquanto as 558 do G2 ocorreram dentre 36174 colonoscopias (1,5%). No G1, 63,4% eram mulheres e no G2 não houve predominância de gênero. O tamanho médio foi no G1, 16,2 mm e no G2, 9,2 mm (p<0,001). G1 predominaram no cólon proximal e G2, no distal e reto (p<0,001). No G1, ocorreram 214 (98,6%) neoplasias mucosas de baixo grau e três de alto grau (1,4%). Excluídos 126 pólipos hiperplásicos e considerados os 91 adenomas sésseis serrilhados, no G1 observou- se 88 (96,7%) neoplasias mucosas de baixo grau e três (3,3%) de alto grau, e no G2, 417 (74,7%) neoplasias mucosas de baixo grau 113 (20,3%) de alto grau e 28 (5,0%) adenocarcinomas invadindo a submucosa (p<0,001). Conclusões: As lesões deprimidas apresentaram significativamente mais neoplasias mucosas de alto grau e carcinomas invasivos para a submucosa do que as serrilhadas superficialmente elevadas e mais do que os adenomas sésseis serrilhados superficialmente elevados.

Which lesions are at higher risk of developing colorectal carcinomas: superficially elevated serrated lesions or depressed lesions? / Quais lesões apresentam maior risco de evolução para carcinomas colorretais: as serrilhadas superficialmente elevadas ou as deprimidas?

ABSTRACT BACKGROUND: There are lesions that are still being missed in colonoscopy. Many of those could be superficially elevated serrated lesions or depressed ones. AIMS: The aim of this study was to compare the histopathological characteristics of these lesions and their risks for submucosal carcinoma. METHODS: This is a retrospective, cross-sectional, and observational study comparing 217 superficially elevated serrated lesions larger than 5 mm resected by colonoscopies (G1) with 558 depressed lesions (G2). RESULTS: In G1, 217 lesions were found in 12,653 (1.7%) colonoscopies; in G2, 558 lesions were found in 36,174 (1.5%) colonoscopies. In G1, 63.4% were women and in G2, there was no gender predominance. The average size of G1 was 16.2 mm and G2 was 9.2 mm (p<0.001). G1 predominated on the proximal colon and G2 on the distal and rectum (p<0.001). In G1, there were 214 (98.6%) low-grade intramucosal neoplasia and 3 (1.4%) high-grade intramucosal neoplasia. Excluding 126 hyperplastic polyps and considering 91 sessile serrated adenomas in G1, we observed 88 (96.7%) low-grade intramucosal neoplasia and 3 (3.3%) high-grade intramucosal neoplasia; in G2, we observed 417 (74.7%) low-grade intramucosal neoplasia, 113 (20.3%) high-grade intramucosal neoplasia, and 28 (5.0%) submucosal adenocarcinomas (p<0.001). CONCLUSION: Depressed lesions significantly had more high-grade intramucosal neoplasia and more invasive carcinomas in the submucosal layer than superficially elevated serrated lesions and more than superficially elevated sessile serrated adenomas.

RESUMO RACIONAL: Há ainda lesões que podem ser perdidas nas colonoscopias. Muitas delas poderiam ser serrilhadas superficialmente elevadas ou deprimidas. OBJETIVO: Comparar as características histopatológicas destas lesões e seus riscos para carcinoma invasivo para a submucosa. MÉTODO: Estudo retrospectivo, transversal, observacional comparando 217 lesões serrilhadas superficialmente elevadas com mais de 5 mm e ressecadas por colonoscopias (G1) com 558 lesões deprimidas (G2). RESULTADOS: As 217 lesões do G1 foram encontradas em 12.653 colonoscopias (1,7%) enquanto as 558 do G2 ocorreram dentre 36.174 colonoscopias (1,5%). No G1, 63,4% eram mulheres e no G2 não houve predominância de gênero. O tamanho médio foi no G1, 16,2 mm e no G2, 9,2 mm (p<0,001). G1 predominaram no cólon proximal e G2, no distal e reto (p<0,001). No G1, ocorreram 214 (98,6%) neoplasias mucosas de baixo grau e três de alto grau (1,4%). Excluídos 126 pólipos hiperplásicos e considerados os 91 adenomas sésseis serrilhados, no G1 observou- se 88 (96,7%) neoplasias mucosas de baixo grau e três (3,3%) de alto grau, e no G2, 417 (74,7%) neoplasias mucosas de baixo grau 113 (20,3%) de alto grau e 28 (5,0%) adenocarcinomas invadindo a submucosa (p<0,001). CONCLUSÕES: As lesões deprimidas apresentaram significativamente mais neoplasias mucosas de alto grau e carcinomas invasivos para a submucosa do que as serrilhadas superficialmente elevadas e mais do que os adenomas sésseis serrilhados superficialmente elevados.

GASTRIC RESIDUAL VOLUME FACTORS AFTER BOWEL PREPARATION WITH MANNITOL EXPRESS.

BACKGROUND: Bowel preparation with mannitol is a well-established method in Brazil. However, factors that interfere with the gastric emptying time period are yet to be known. Knowing these factors may favor the examination scheduling logistics and the individualized orientation for each patient. OBJECTIVE: Know the factors that can contribute to the gastric emptying time after intestinal preparation with express mannitol. METHODS: This is a prospective observational study to know factors that may contribute on the gastric emptying timing: predominant type of diet, comorbidities, medication usage, previous surgeries, number of evacuation per week, bearer of bowel obstipation, fecal type, diet type, number of evacuations after the home usage of bisacodyl before the ingestion of mannitol and number of evacuations after the ingestion of mannitol until reaching a proper bowel preparation. Before starting the colonoscopy exam, an upper digestive endoscopy exam was made to aspirate the gastric content. RESULTS: Sample was composed of 103 patients, 55 (53.4%) women, medium age 61 (±12.1) years, medium weight 75.3 (±14.1) kg, medium height 1.7 (±10) m and medium BMI of 26.6 (±3.9) kg/m2. Average gastric residual volume was 120.9 (0-900) mL. Gastric residual volume (GRV) below 100 mL (GRV ≤100 mL) occurred in 45 (43.6%) patients, 24 (53.3%) women, medium age of 61.0 years and medium BMI of 26.7 kg/m2. Gastric residual volume above 100 mL (GRV >100 mL) occurred on 58 (56.3%) patients, 29 (50%) women, medium age of 61.0 years and medium BMI of 26.2 kg/m2. Comparing both groups, average fasting time period after the ingestion of mannitol was significantly higher on the group with GRV ≤100 mL than group with GRV >100 mL, 123.1 (60-246) vs 95.3 (55-195) minutes, respectively. There was also statistical significance concerning the usage of ezetimibe 6 (13.7%) in the group with GRV ≤100 mL and statistical significance in the group with GRV >100 mL concerning the usage of paroxetine 3 (6.7%) and tadalafil 3 (6.7%) and surgical history of prostatectomy 3 (6.7%) and bridle withdrawal 3 (6.7%). CONCLUSION: We may conclude in this study that the usage of ezetimibe and fasting above 2 hours after the ingestion of mannitol decrease significantly the incidence of a GRV >100 mL. The usage of paroxetine, tadalafil and surgical history of prostatectomy or bridle withdrawal may contribute to increase de incidence of a GRV >100 mL.

Comparison of endoscopic resection techniques for duodenal neuroendocrine tumors: systematic review.

Background and study aims Regardless of size, duodenal neuroendocrine tumors (dNETs) should be considered potentially malignant. A complete resection without complications is essential to increase safety procedures. The aim of this review was to describe effectiveness and possible complications of endoscopic techniques resection for resectioning dNETs in patients with tumors ≤ 20 mm in diameter. Methods An electronic bibliographic search was conducted using MEDLINE (via PubMed), Embase, Cochrane Central, and Google Scholar virtual databases. The types of intervention were endoscopic mucosal resection alone (EMR) or with cap (EMR-C), with a ligation device (EMR-L), with previous elevation of the tumor (EMR-I) or with endoscopic submucosal dissection (ESD); argon plasm coagulation (APC), and polypectomy. The outcome measures adopted were presence of free margin associated with tumor resection, tumor recurrence, complications (bleeding and perforation), and length of the procedure. Results Ten publications were included with the result of 224 dNET resections. EMR alone and polypectomy resulted in the most significantly compromised margin. The most frequent complication was bleeding (n = 21), followed by perforation (n = 8). Recurrence occurred in 13 cases, the majority of those under EMR or EMR-I. Conclusions EMR-C or EMR-I should be preferred for resectioning of dNETs. Polypectomy should not be indicated for resection of dNETs due to the high occurrence of incomplete resections. EMR alone must be avoided due a higher frequency of compromised margin and recurrent surgery. ESD was associated with no recurrence, however, but an increased occurrence of bleeding and perforation.

Fatores predisponentes do volume residual gástrico após preparo expresso com manitol / Gastric residual volume factors after bowel preparation with mannitol express

ABSTRACT BACKGROUND: Bowel preparation with mannitol is a well-established method in Brazil. However, factors that interfere with the gastric emptying time period are yet to be known. Knowing these factors may favor the examination scheduling logistics and the individualized orientation for each patient. OBJECTIVE: Know the factors that can contribute to the gastric emptying time after intestinal preparation with express mannitol. METHODS: This is a prospective observational study to know factors that may contribute on the gastric emptying timing: predominant type of diet, comorbidities, medication usage, previous surgeries, number of evacuation per week, bearer of bowel obstipation, fecal type, diet type, number of evacuations after the home usage of bisacodyl before the ingestion of mannitol and number of evacuations after the ingestion of mannitol until reaching a proper bowel preparation. Before starting the colonoscopy exam, an upper digestive endoscopy exam was made to aspirate the gastric content. RESULTS: Sample was composed of 103 patients, 55 (53.4%) women, medium age 61 (±12.1) years, medium weight 75.3 (±14.1) kg, medium height 1.7 (±10) m and medium BMI of 26.6 (±3.9) kg/m2. Average gastric residual volume was 120.9 (0-900) mL. Gastric residual volume (GRV) below 100 mL (GRV ≤100 mL) occurred in 45 (43.6%) patients, 24 (53.3%) women, medium age of 61.0 years and medium BMI of 26.7 kg/m2. Gastric residual volume above 100 mL (GRV >100 mL) occurred on 58 (56.3%) patients, 29 (50%) women, medium age of 61.0 years and medium BMI of 26.2 kg/m2. Comparing both groups, average fasting time period after the ingestion of mannitol was significantly higher on the group with GRV ≤100 mL than group with GRV >100 mL, 123.1 (60-246) vs 95.3 (55-195) minutes, respectively. There was also statistical significance concerning the usage of ezetimibe 6 (13.7%) in the group with GRV ≤100 mL and statistical significance in the group with GRV >100 mL concerning the usage of paroxetine 3 (6.7%) and tadalafil 3 (6.7%) and surgical history of prostatectomy 3 (6.7%) and bridle withdrawal 3 (6.7%). CONCLUSION: We may conclude in this study that the usage of ezetimibe and fasting above 2 hours after the ingestion of mannitol decrease significantly the incidence of a GRV >100 mL. The usage of paroxetine, tadalafil and surgical history of prostatectomy or bridle withdrawal may contribute to increase de incidence of a GRV >100 mL.

RESUMO CONTEXTO: O preparo intestinal com manitol é um método bem estabelecido no Brasil. No entanto, os fatores que interferem no tempo de esvaziamento gástrico ainda não são conhecidos. O conhecimento desses fatores pode favorecer a logística de agendamento do exame e a orientação individualizada para cada paciente. OBJETIVO: Estudar os fatores que podem contribuir para o tempo de esvaziamento gástrico após o preparo intestinal com manitol expresso. MÉTODOS: Trata-se de um estudo observacional prospectivo com o objetivo de conhecer os seguintes fatores que podem contribuir no tempo de esvaziamento gástrico: tipo de dieta predominante, comorbidades, uso de medicamentos, cirurgias anteriores, número de evacuações por semana, portador de obstipação intestinal, tipo fecal, tipo de dieta, número de evacuações após o uso domiciliar de bisacodil antes da ingestão de manitol e número de evacuações após a ingestão de manitol até atingir o preparo intestinal adequado. Antes de iniciar o preparo intestinal, os pacientes responderam a um questionário clínico. O endoscópio foi introduzido para aspirar o conteúdo gástrico, antes de iniciar a colonoscopia. RESULTADOS: A amostra foi composta por 103 pacientes, sendo 55 mulheres, com média de idade de 61 anos, peso médio de 75,3 kg, altura média de 1,7 m e IMC médio de 26,6 kg/m2. O volume residual gástrico médio medido foi 120,9 (0-900) mL. Volume residual gástrico inferior a 100 mL (VRG ≤100 mL) foi encontrado em 45 (43,6%) pacientes, sendo 24 (53,3%) mulheres, com média de idade de 61,0 anos e IMC médio de 26,7 kg/m2. Volume residual gástrico acima de 100 mL (VRG >100 mL) ocorreu em 58 (56,3%) pacientes, sendo 29 (50%) mulheres, com idade média de 61,0 anos e IMC médio de 26,2 kg/m2. Comparando os dois grupos, notou-se que o tempo médio de jejum após a ingestão de manitol foi significativamente maior no grupo com VRG ≤100 mL do que no grupo com VRG> 100 mL, 123,1 (60-246) vs 95,3 (55-195) minutos, respectivamente. Também houve significância estatística em relação ao uso de ezetimiba 6 (13,7%), sendo maior no grupo com VRG ≤100 mL. Além disso, houve significância estatística no grupo com VRG >100 mL quanto ao uso de paroxetina 3 (6,7%) e tadalafil 3 (6,7%) e história cirúrgica de prostatectomia 3 (6,7%) e retirada de bridas 3 (6,7%). CONCLUSÃO: Podemos concluir neste estudo que o uso de ezetimiba e o jejum acima de 2 horas após a ingestão de manitol diminuem significativamente a incidência de um VRG> 100 mL. O uso de paroxetina, tadalafil e história cirúrgica de prostatectomia ou retirada de bridas podem contribuir para o aumento da incidência de um VRG >100 mL.

Underwater endoscopic mucosal resection of serrated adenomas.

OBJECTIVES: Serrated polyps, which are considered to be precursors of colorectal carcinoma, include hyperplastic polyps, sessile serrated adenomas and traditional serrated adenomas. With the exception of hyperplastic polyps, all of these lesions must be removed. This study sought to examine whether underwater endoscopic mucosal resection is a safe and effective technique for treating serrated polyps. METHODS: Cases in which patients were submitted for underwater endoscopic mucosal resection and histologically diagnosed with sessile serrated adenoma were prospectively registered. RESULTS: The median patient age was 54.5 years (range, 48 to 72 years), and the patients included 4 men (28.5%) and 10 women (71.5%). One lesion (6.2%), 10 lesions (62.5%), 1 lesion (6.2%), 3 lesions (18.8%) and 1 lesion (6.2%) were found in the cecum, the ascending colon, the hepatic flexure, the transverse colon and the descending colon, respectively. The median lesion size was 20 mm (range, 10 to 35 mm). Eight lesions (50%) were removed en bloc, and the remaining eight lesions (50%) were removed using a piecemeal technique. None of the cases were complicated by perforation or delayed bleeding. CONCLUSION: Underwater resection could be a feasible, safe and effective alternative for the resection of sessile serrated adenomas.

Video capsule endoscopy vs double-balloon enteroscopy in the diagnosis of small bowel bleeding: A systematic review and meta-analysis.

AIM: To compare the diagnostic accuracy of video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) in cases of obscure gastrointestinal bleeding (OGIB) of vascular origin. METHODS: MEDLINE (via PubMed), LILACS (via BVS) and Cochrane/CENTRAL virtual databases were searched for studies dated before 2017. We identified prospective and retrospective studies, including observational, cohort, single-blinded and multicenter studies, comparing VCE and DBE for the diagnosis of OGIB, and data of all the vascular sources of bleeding were collected. All patients were subjected to the same gold standard method. Relevant data were then extracted from each included study using a standardized extraction form. We calculated study variables (sensitivity, specificity, prevalence, positive and negative predictive values and accuracy) and performed a meta-analysis using Meta-Disc software. RESULTS: In the per-patient analysis, 17 studies (1477 lesions) were included. We identified 3150 exams (1722 VCE and 1428 DBE) in 2043 patients and identified 2248 sources of bleeding, 1467 of which were from vascular lesions. Of these lesions, 864 (58.5%) were diagnosed by VCE, and 613 (41.5%) were diagnosed by DBE. The pretest probability for bleeding of vascular origin was 54.34%. The sensitivity of DBE was 84% (95%CI: 0.82-0.86; heterogeneity: 78.00%), and the specificity was 92% (95%CI: 0.89-0.94; heterogeneity: 92.0%). For DBE, the positive likelihood ratio was 11.29 (95%CI: 4.83-26.40; heterogeneity: 91.6%), and the negative likelihood ratio was 0.20 (95%CI: 0.15-0.27; heterogeneity: 67.3%). Performing DBE after CE increased the diagnostic yield of vascular lesion by 7%, from 83% to 90%. CONCLUSION: The diagnostic accuracy of detecting small bowel bleeding from a vascular source is increased with the use of an isolated video capsule endoscope compared with isolated DBE. However, concomitant use increases the detection rate of the bleeding source.

Underwater endoscopic mucosal resection of serrated adenomas

OBJECTIVES: Serrated polyps, which are considered to be precursors of colorectal carcinoma, include hyperplastic polyps, sessile serrated adenomas and traditional serrated adenomas. With the exception of hyperplastic polyps, all of these lesions must be removed. This study sought to examine whether underwater endoscopic mucosal resection is a safe and effective technique for treating serrated polyps. METHODS: Cases in which patients were submitted for underwater endoscopic mucosal resection and histologically diagnosed with sessile serrated adenoma were prospectively registered. RESULTS: The median patient age was 54.5 years (range, 48 to 72 years), and the patients included 4 men (28.5%) and 10 women (71.5%). One lesion (6.2%), 10 lesions (62.5%), 1 lesion (6.2%), 3 lesions (18.8%) and 1 lesion (6.2%) were found in the cecum, the ascending colon, the hepatic flexure, the transverse colon and the descending colon, respectively. The median lesion size was 20 mm (range, 10 to 35 mm). Eight lesions (50%) were removed en bloc, and the remaining eight lesions (50%) were removed using a piecemeal technique. None of the cases were complicated by perforation or delayed bleeding. CONCLUSION: Underwater resection could be a feasible, safe and effective alternative for the resection of sessile serrated adenomas.

Underwater endoscopic resection: an alternative for difficult colorectal polyps.

BACKGROUND AND AIMS: Underwater endoscopic resection can be an alternative to standard resection techniques to remove difficult colorectal polyps. This video shows 4 cases of underwater resection of large colorectal polyps. METHODS: Underwater resection consists of complete filling of the lumen through the accessory channel, using an infusion pump followed by snare resection of the polyp. We present 4 cases: a 3-cm pseudodepressed laterally spreading tumor (LST) in the sigmoid colon, a 6-cm pedunculated polyp with a thick stalk in the sigmoid, a 7-cm sessile lesion in the midrectum, and a 4-cm LST in the distal rectum close to the dentate line, resected with a monofilament snare or a multifilament snare. RESULTS: All tumors were successfully resected without any adverse events or residual lesions during follow-up. CONCLUSIONS: The underwater technique is a good alternative to standard resection techniques to remove difficult colorectal lesions.