Long-term outcomes after endoscopic removal of malignant colorectal polyps:Results from a 10-year cohort

BACKGROUND Choosing an optimal post-polypectomy management strategy of malignant colorectal polyps is challenging,and evidence regarding a surveillance-only strategy is limited.AIM To evaluate long-term outcomes after endoscopic removal of malignant colorectal polyps.METHODS A single-center retrospective cohort study was conducted to evaluate outcomes after endoscopic removal of malignant colorectal polyps between 2010 and 2020.Residual disease rate and nodal metastases after secondary surgery and local and distant recurrence rate for those with at least 1 year of follow-up were invest-igated.Event rates for categorical variables and means for continuous variables with 95%confidence intervals were calculated,and Fisher’s exact test and Mann-Whitney test were performed.Potential risk factors of adverse outcomes were RESULTS In total,135 lesions(mean size:22.1 mm;location:42%rectal)from 129 patients(mean age:67.7 years;56%male)were enrolled.The proportion of pedunculated and non-pedunculated lesions was similar,with en bloc resection in 82%and 47%of lesions,respectively.Tumor differentiation,distance from resection margins,depth of submucosal invasion,lymphovascular invasion,and budding were reported at 89.6%,45.2%,58.5%,31.9%,and 25.2%,respectively.Residual tumor was found in 10 patients,and nodal metastasis was found in 4 of 41 patients who underwent secondary surgical resection.Univariate analysis identified piecemeal resection as a risk factor for residual malignancy(odds ratio:1.74;P=0.042).At least 1 year of follow-up was available for 117 lesions from 111 patients(mean follow-up period:5.59 years).Overall,54%,30%,30%,11%,and 16%of patients presented at the 1-year,3-year,5-year,7-year,and 9-10-year surveillance examinations.Adverse outcomes occurred in 9.0%(local recurrence and dissemination in 4 patients and 9 patients,respectively),with no difference between patients undergoing secondary surgery and surveillance only.CONCLUSION Reporting of histological features and adherence to surveillance colonoscopy needs improvement.Long-term adverse outcome rates might be higher than previously reported,irrespective of whether secondary surgery was performed.

Endoscopic removal of foreign bodies:A retrospective study in Japan

BACKGROUND The ingestion of foreign bodies(FBs)and food bolus impaction(FBI)in the digestive tract are commonly encountered clinical problems.Methods to handle such problems continue to evolve offering advantages,such as the avoidance of surgery,reduced cost,improved visualization,reduced morbidity,and high removal success rate.However,to date,no studies have evaluated the endoscopic management of FBs in Japan.AIM To elucidate level of safety and efficacy in the endoscopic management of FBs and FBI.METHODS A total of 215 procedures were performed at Keio University Hospital between November 2007 and August 2018.Data were collected from medical charts,and endoscopic details were collected from an endoscopic reporting system.Procedures performed with a flexible gastrointestinal endoscope were only taken into account.Patients who underwent a technique involving FB or FBI from the digestive tract were only included.Data on patient sex,patient age,outpatient,inpatient,FB type,FB location,procedure time,procedure type,removal device type,success,and technical complications were reviewed and analyzed retrospectively.RESULTS Among the 215 procedures,136(63.3%)were performed in old adults(≥60 years),180(83.7%)procedures were performed in outpatients.The most common type of FBs were press-through-pack(PTP)medications[72(33.5%)cases],FBI[47(21.9%)],Anisakis parasite(AP)[41(19.1%)cases].Most FBs were located in the esophagus[130(60.5%)cases]followed by the stomach[68(31.6%)cases].AP was commonly found in the stomach[39(57.4%)cases],and it was removed using biopsy forceps in 97.5%of the cases.The most common FBs according to anatomical location were PTP medications(40%)and dental prostheses(DP)(40%)in the laryngopharynx,PTP(48.5%)in the esophagus,AP(57.4%)in the stomach,DP(37.5%)in the small intestine and video capsule endoscopy device(75%)in the colon.A transparent cap with grasping forceps was the most commonly used device[82(38.1%)cases].The success rate of the procedure was 100%,and complication were observed in only one case(0.5%).CONCLUSION Endoscopic management of FBs and FBI in our Hospital is extremely safe and effective.

Nomogram to predict the risk of endoscopic removal failure with forceps/baskets for treating submandibular stones

BACKGROUND Endoscopic removal with forceps/baskets is favored in treating submandibular stones due to its minimal invasiveness.However,recent studies have found that endoscopic removal failure(ERF)is not unusual,and stones in such cases still need to be removed with other surgical methods.If the risk of ERF can be predicted preoperatively,it could be helpful for surgeons when choosing the appropriate therapy.AIM To develop a predictive nomogram for the risk of ERF when treating submandibular stones based on their preoperative clinical features.METHODS A total of 180 patients with 211 submandibular stones treated from January 2012 to December 2020 were included in the current study.Based on the preoperative clinical features of the stones,independent risk factors for ERF were identified by logistic regression analysis.The stones were then randomly divided into training and testing sets.A nomogram was constructed to predict the risk of ERF using the training set and then validated using both sets.The predictive performance of the nomogram was assessed by calibration curves and the concordance index(Cindex).RESULTS Three independent predictors,location(P=0.040),transverse diameter(P<0.001)and longitudinal diameter(P<0.001)measured on the cone beam computed tomography(CBCT)images of the submandibular stones,were identified and included in the predictive nomogram.Calibration curves of the nomogram showed good agreement between the predicted and observed probabilities in both sets.The C-index in the training set was 0.917(95%CI,0.875-0.959)and that in the testing set was 0.925(95%CI,0.862-0.989).CONCLUSION A nomogram based on the location,transverse and longitudinal diameters on CBCT images of submandibular stones showed satisfactory efficacy in predicting the risk of ERF preoperatively when treating submandibular stones.

A Case Report on Gallstone Ileus Treated with the Endoscopy

An 85-year-old female patient visited our emergency department with a history of lower abdominal pain and vomiting. Abdominal plain CT showed small bowel obstruction caused by a gallstone measuring 3 cm in size in the terminal ileum, gas in the gallbladder and adhesion in the gallbladder and duodenum. Thus, gallstone ileus with a cholecystoduodenal fistula was diagnosed. The gallstone was removed by the lower gastrointestinal endoscopy. Because of the high-risk status of the patient surgery, such as cholecystectomy or resection of the cholecystoduodenal fistula was not performed. Upper gastrointestinal endoscopy and radiography revealed the cholecystoduodenal fistula in the anterior wall of the duodenal bulb. Upper gastrointestinal radiography showed that the cholecystoduodenal fistula had been closed spontaneously without any complications on the 13th hospital day. Endoscopic removal of gallstone causing ileus is safe and effective as a less invasive alternative compared with surgery, although it requires condition that endoscope could reach the gallstone. The treatment method for the cholecystoduodenal fistula should be selected keeping in mind that conservative treatment, without surgery, may be effective.