Volume 84 - 2021 - Fasc.3 - Original articles
A single-centre analysis of post-colonoscopy colorectal cancer
Patients and methods: A prospective registration of patients
with colorectal cancer and a colonoscopy within the last 10 years.
We tried to classify these post-colonoscopy colorectal cancers
(PCCRCs) by most reasonable explanation and into subcategories
suggested by the World Endoscopy Organization (WEO) and
calculated the unadjusted PCCRC rate.
Results: 47 PCCRCs were identified. The average age at
diagnosis of PCCRC was 73 years. PCCRCs were more located
in the right colon with a higher percentage of MSI-positive and
B-RAF mutated tumours. The average period between index
colonoscopy and diagnosis of PCCRC was 4.2 years. Sixty-eight %
of all PCCRCs could be explained by procedural factors. The mean
PCCRC-3y of our department was 2.46%.
Conclusions: The data of our centre are in line with the data
of the literature from which can be concluded that most postcolonoscopy
colorectal cancers are preventable. The PCCRC-3y is
an important quality measure for screening colonoscopy. Ideally
all centres involved in the population screening should measure
the PCCRC-3 y annually, with cooperation of the cancer registry
and reimbursement data provided by the Intermutualistic Agency
Effect of physician-provided education on the quality of bowel preparation
Background and study aims: Inadequate bowel preparation in
patients scheduled for colonoscopy is an important problem. In
our study, we aimed to investigate the effect of physician-provided
bowel preparation education on the quality of bowel preparation
Patients and methods: A total of 150 outpatients who were referred
to Kocaeli University Medical Faculty Hospital Gastroenterology
Unit for colonoscopy between May 2019 and October 2019 were
enrolled in our prospective, endoscopist-blinded study. Patients
were divided into two groups. Group 1 (education group) included
73 patients who received 10 minutes of verbal information from
a physician in addition to a written information form. Group 2
(control group) included 75 patients who received information
from a medical secretary in addition to a written information form.
During colonoscopy, the quality of bowel preparation was assessed
using the Boston bowel preparation scale (BBPS). A BBPS score
≥ 5 was considered adequate bowel preparation. The mean BBPS
score, polyp detection rate, cecal intubation rate and time, and
procedure time were also evaluated.
Results: The rate of adequate bowel preparation (BBPS score
≥ 5) was 90.4% and 74.7% in groups 1 and 2, respectively (p =
0.021). The odds ratio for having a BBPS score ≥ 5 in the education
group was 3.199 compared with the control group (95% confidence
interval = 1.254-8.164; p = 0.015). The cecal intubation rates were
91.8% and 88% in groups 1 and 2, respectively (p > 0.05). The cecal
intubation time, procedure time, and adenoma detection rates were
similar between the groups. The relationships of age, education
level, sex, diabetes mellitus, medicine use, procedure time, and
intraabdominal surgery with inadequate bowel preparation
were analysed using a logistic regression model. Univariate and
multivariate analyses revealed no significant factors associated
with inadequate bowel preparation.
Conclusions: Patient education on the bowel preparation
process via a physician improved the quality of bowel preparation.
Pedunculated colorectal polyps with heads ≤ 1 cm in diameter can be resected using cold snare polypectomy
Background and study aims: Cold snare polypectomy (CSP)
is not recommended for the resection of pedunculated colorectal
polyp. The aim of this study was to examine the adequacy of
CSP compared to hot snare polypectomy (HSP) for the complete
resection of pedunculated polyps with heads ≤ 1 cm in diameter.
Patients and methods: This was a retrospective study of a cohort
of consecutive outpatients who had resection of pedunculated
polyps with heads 6-10 mm in diameter using either dedicated CSP
or HSP from 2014 through 2019. The primary outcome measure
was occurrence of delayed bleeding. Secondary outcome measures
included total procedure time, en bloc resection rate, immediate
bleeding, and number of clips used.
Results: 415 patients with 444 eligible polyps were enrolled; the
CSP group (363 patients; 386 polyps) and HSP group (52 patients;
58 polyps). Patient characteristics, polyp characteristics and en
bloc resection rate were similar between groups. The mean total
procedure time and mean number (range) of hemostatic clips/
patient used were significantly lower with CSP than with HSP
(18± 8 min vs. 25± 9 min, P<0.001; 1.1 ± 0.6 (1-3) vs.3.1 ± 1.6 (1-5),
respectively, P<0.001). Delayed bleeding occurred significantly less
frequently in the CSP, 0% (0/363 vs.3.8% (2/52) in the HSP group
(P<0.001), although immediate bleeding was significantly higher in
CSP than HSP (84% (325/386) vs. 12% (7/58), P<0.001).
Conclusion: Pedunculated colorectal polyps with heads ≤ 1 cm
can be removed using CSP, which has several advantages over HSP.
Real world management of esophageal ulcers: analysis of their presentation, etiology, and outcomes
Background and study aims: Esophageal ulcers are a rare cause
of upper gastrointestinal morbidity and may be due to different
etiologies. We sought to systematically evaluate patients with
esophageal ulcers and describe their presentations, endoscopic
findings, etiologies, treatments, and outcomes.
Patients and methods: Patients diagnosed with esophageal ulcers
over an 11-year period were retrospectively identified from our
institution’s electronic medical records.
Results: We identified 100 patients with esophageal ulcers
(0.49% of patients undergoing upper endoscopy). Half of them
presented due to gastrointestinal bleeding and three-quarters were
admitted to the hospital. The majority were in the lower esophagus.
Twenty-two unique etiologies, including multiple iatrogenic causes,
were diagnosed in 91 of the cases. The most common etiology was
gastroesophageal reflux disease (57%), followed by non-steroidal
anti-inflammatory drug use (7%), malignancies (3%), vomiting
(3%), caustic ingestion (2%), pill esophagitis (2%) and radiation
(2%). Many etiologies showed a predilection for specific segments
of the esophagus. Nine ulcers required endoscopic intervention and
all were treated successfully. Repeat endoscopies were performed
5 times for diagnostic or “second look” reasons, none of which
changed the patients’ diagnosis or treatment. No patients required
surgery or stricture dilation. One patient’s ulcer was complicated
by perforation and he subsequently died. Four other patients died
from non-ulcer related causes.
Conclusions: While the majority of ulcers were due to gastroesophageal
reflux disease, 22 different etiologies were identified.
Many were due to medication or iatrogenic causes. Repeat endoscopy
did not appear to be helpful. While the incidence was low,
they were frequently associated with significant morbidity.
Efficacy of switching from infliximab to golimumab in patients with ulcerative colitis in deep remission
Background-Aim: Intravenously administered biologicals are
associated with a huge pressure to Infusion Units and increased
cost. We aimed to assess the impact of switching infliximab to
golimumab in ulcerative colitis (UC) patients in deep remission.
Patients and method: In a prospective, single-centre pilot study
UC patients on infliximab mono-therapy for ≥ 2 years, whowere
in deep remission, consented to switch to golimumab and were
followed for 1 year with clinical assessment, serum and faecal
biomarkers, work productivity, satisfaction with treatment and
quality of life parameters. Endoscopic remission was assessed by
colonoscopy at 1 year. Patients fulfilling the same inclusion criteria,
who did not consent to switch to golimumab and continued to
receive infliximab mono-therapy, for the same period, served as
Results: Between October 2015 and October 2017, 20 patients
were recruited; however one patient stopped therapy because of
pregnancy. All 19 patients who were switched to golimumab were
still in clinical, biomarker and endoscopic remission at 1 year and
maintained excellent quality of life without any complications. In
the control group, 18 of 19 patients were also in deep remission,
since only one patient had a flare which was managed with IFX
dose intensification. During a median 3 years extension treatment
with golimumab only 2 patients experienced a flare of colitis.
Conclusions: This pilot study indicates that switching from
in-fliximab to golimumab in UC patients in deep remission does
not compromise treatment effectiveness or the course of disease;
golimumab offers a valid alternative to intravenous infliximab
infusions during the COVID-19 pandemic.
Prucalopride in intestinal pseudo obstruction, paediatric experience and systematic review
Background : Intestinal pseudo obstruction both acute and
chronic is an uncommon severe motility disorder that affect both
children and adults, can lead to significant morbidity burden and
have no standard management strategy. Prucalopride a highly
selective serotonin receptor agonist is an effective laxative with
reported extra colon action.
We aim to report our experience in children with acute
and chronic intestinal pseudo obstruction who responded to
prucalopride and systemically review the use of prucalopride in
intestinal pseudo obstruction.
Methods : A report of clinical experience and systemic review of
the relevant medical databases to identify the outcome of usage of
prucalopride in patients with acute and chronic intestinal pseudo
obstruction. Studies meeting the selection criteria were reviewed
including abstract only and case reports.
Results : All reported cases showed clinical response to
prucalopride. There were three full text, two abstracts only
and three case reports all reporting clinical improvement with
Conclusion : Prucalopride appears to show promising results
in children and adults with acute and chronic intestinal pseudo
A practical means of evaluating the prognosis of acute pancreatitis, as measurement of carotid artery intima-media thickness
Backgroung and study aims: Factors such as age, obesity,
diabetes mellitus and hyperlipidemia that cause adverse prognosis
in acute pancreatitis also cause an increase in carotid intima-media
thickness. In this study, we aimed to investigate the usability of the
measurement of carotid intima-media thickness, which is an easy to
apply, cost-effective means of measurement applied to the patients,
in predicting AP prognosis, apart from the criteria currently
utilized to predict AP prognosis.
Patient and methods: 101 patients diagnosed with acute
pancreatitis were prospectively enrolled into the study. Right and
left common carotid artery intima-media thickness, right and left
internal carotid artery intima-media thickness were measured with
ultrasonographic images performed within the first 24 hours of
hospitalization. local or systemic complications and organ failure
development were monitored in the follow-up of the patients.
Results: After the ROC analysis was performed and the
threshold value was determined. The patients with main and
internal carotid artery intima-media thickness above 0.775 mm
were seen to have a more severe AP (p = 0.000). Local and systemic
complications and organ failure were also more common in these
Conclusions: Measurement of carotid intima-media thickness is
a non-invasive method that can be used to predict the prognosis in
patients with acute pancreatitis at presentation.
Evaluating the accuracy of three international guidelines in identifying the risk of malignancy in pancreatic cysts: a retrospective analysis of a surgical treated population
Background and study aims: The international consensus
Fukuoka guideline (Fukuoka ICG), The European evidence-based
guideline on pancreatic cystic neoplasms (European EBG) and
the American Gastroenterological Association institute guideline
on the diagnosis and management of asymptomatic neoplastic
pancreatic cysts (AGA IG) are 3 frequently cited guidelines for
the risk stratification of neoplastic pancreatic cysts. The aim of
this study was to assess the accuracy of detecting malignant cysts
by strictly applying these guidelines retrospectively to a cohort of
surgically resected pancreatic cysts.
Patient and methods: 72 resected cysts were included in
the analysis. Invasive carcinoma, high grade dysplasia and
neuro-endocrine tumour were considered as “malignant cysts” for
the purpose of the study.
Results: 32% of the resected cysts were malignant. The analysis
showed that the Fukuoka ICG, European EBG and AGA IG had
a sensitivity of 66,8%, 95,5%, 80%; a specificity of 26,8%, 11,3%,
43,8%; a positive predictive value of 31,8%, 35%, 47,1% and a
negative predicted value of 61,1%, 83,3%, 77,8% respectively. The
missed malignancy rate was respectively 11,3%, 1,5%, 7,7% and
surgical overtreatment was respectively 48,4%, 59,1%, 34,6%.
Conclusion: In this retrospective analysis, the European EBG
had the lowest rate of missed malignancy at the expense of a high
number of “unnecessary” resections. The Fukuoka ICG had the
highest number of missed malignancy. The AGA IG showed the
lowest rate of unnecessary surgery at the cost of a high number of
missed malignancy. There is need to develop better biomarkers to
predict the risk of malignancy.
Accuracy and other quality indicators of solid pancreatic mass endoscopic ultrasound-guided fine needle aspiration and biopsy in two academic endoscopy centers
Background and aims: Endoscopic ultrasound fine-needle
aspiration/biopsy (EUS-FNA/FNB) is highly accurate, but
discrepancies between cytological and surgical diagnoses are still
observed. We aimed to determine its accuracy and monitor quality
indicators in our facilities.
Patients and methods: We performed a retrospective review of
all cases of pancreatic solid lesions evaluated by EUS-FNA/FNB,
between July 2015 and June 2018, in two centers. Cytological
and surgical findings were categorized into five groups: benign,
malignant, suspect of malignancy, undetermined and insufficient
for diagnosis. Final diagnosis was based on surgical diagnosis and,
in patients who did not undergo surgery, on clinical outcome after
6 months follow-up.
Results: Altogether, 142 patients were included. FNA was the
preferred tissue acquisition method (88%), with a predilection for
the FNA 22G needle (57%). Cytology was insufficient for diagnosis
in 2 cases, therefore a full diagnostic sample was available in 98.6%
of the patients (>90%, ESGE target). Fifty-five (38.7%) patients
underwent surgery. In term of cancer diagnosis, comparison with
final surgical pathology (n=55) revealed 89% true positives, 5.5%
true negatives, 3.6% false positives and 1.8% false negatives.
When combining surgical diagnosis and clinical outcomes together,
EUS-guided sampling sensitivity was 97.4% (92.5-99.5), specificity
was 92.3% (74.9-99.1), positive predictive value was 98.2% (93.6-
99.5), negative predictive value was 88.9% (72.3-96.1) and accuracy
was 96.4% (91.9-98.8). Post-procedural acute pancreatitis was
reported in 2 patients (1.4%).
Conclusions: These results reveal a performance for diagnostic
tissue sampling well above the ESGE proposed target standard.
Also, the uncommon high specificity illustrates the determining
role of the pathologist’s final interpretation and diagnosis.
Lessons learned about appendiceal neuroendocrine neoplasms from data analysis of the Belgian Cancer Registry 2010-2015
Background and study aims: Appendiceal neuroendocrine neo-
plasms (aNENs) are a diverse group of malignant neoplasms of varying biological behavior for which information about manage-ment and outcome is sparse, with the majority of available studies being retrospective, including only a limited number of patients, and therefore not necessarily reflecting the reality in the community. In the present study clinical, epidemiological and pathological data of appendiceal neuroendocrine neoplasms in Belgium is provided and compared with current literature.
Methods: A population-based study was conducted by linking data of the Belgian Cancer Registry with medical procedures in the Belgian Health Insurance database for patients diagnosed with aNEN between 2010 and 2015.
Results: We found an aNEN incidence of 0.97/100.000 person years in Belgium. Neuroendocrine carcinoma of the appendix are rare. Most appendiceal neuroendocrine tumors (aNETs) are small G1 tumors. Positive lymph nodes are often found in tumors larger than 2cm, especially aNET G2.
Conclusion: A rapid uptake of changing classifications was seen in the community. However, systematic reporting of risk factors for small aNEN can still be improved and should be stimulated. In 9% of cases, reclassifications had to be made, pointing out that in a retrospective analysis, original pathological reports should be checked for specific parameters, before reliable conclusions can be drawn.