Finding and Removing Difficult Polyps (safely) David Lieberman MD Chief, Division of Gastroenterology and Hepatology Oregon Health and Science University
Colonoscopy Clouds Interval Cancers
Interval Cancer: What is the risk? After Polypectomy Incidence: 0.3-0.9% in 3-5 yrs 1.7-2.8 cancers /1000 person yrs After (-) Colonoscopy 2-9% of ALL cancers (within 6-36 months) Pabby, GIE 2005; 61: 385-91 Alberts; NEJM 2000 342: 1156-62 Robertson; Gastroenterol 2005;129:34-41 Bertagnolli; NEJM 2006;355:873-84 Arber; NEJM 2006; 355:885-95 Baron; Gastroenterol 2006; 131:1674-82 Lieberman; Gastroenterol 2007; 133: 1077-85 Cooper et al; Gastroenterol 2010: 138: S24 Singh, Am J Gastroenterol 28 Sept 2010 on line Baxter et al; Gastroenterol 2011; 140: 65-72
CRC risk reduction with colonoscopy Study n F/U CRC risk Notes Singh, 2006 Manitoba Bressler, 2007 Ontario Prevalent vs Incident CRC Lakoff, 2008 Ontario Baxter, 2009 Ontario Case-Control 35,975 (-) colonoscopy 5 SIR 0.55 (0.41-0.73) Proximal CRC 28% of prevalent CRC 47% of interval CRC 12,427 CRC cases 3 Proximal CRC 32% of prevalent CRC 55% of interval CRC Less protection or No protection in Proximal Colon 110,402 (-) CSP 14 RR 0.25 (0.12-0.37) 10,292 CRC cases Mortality OR =0.69 (0.63-0.74) Proximal CRC No reduction in risk until year #8 of f/u Proximal CRC OR=0.99 Distal CRC OR=0.33 (0.28-0.39) Brenner, 2011 Germany Case-Control 1688 CRC cases 10 OR (all) 0.23 Proximal CRC OR=0.44 Distal CRC OR 0.16 Singh;JAMA 2006;295:2366-73 Bressler; Gastroenterol 2007; 132:96-102 Lakoff; ClinGastro Hep 2008;6:1117-21 Baxter;Ann Intern Med 2009; 150:1-8 Brenner Ann Intern Med 2011; 154:22-30
Interval Cancer: WHY? New, fast growing lesions Sawhney et al; Gastroenterology 2006; 131: 1700-5 Incomplete removal (19-27%) Pabby et al; Gastrointest Endosc 2005; 61: 385-91 Soetikno;JAMA 2008; 299: 1027-35 Farrar; CGH 2006; 4: 1259-64
Interval Cancer: WHY? New, fast growing lesions Incomplete removal (19-27%) Missed lesions 2-12% of polyps > 1cm are missed!! Less protection in proximal colon
Robertson, Lieberman, Winawer; DDW 2008 Interval Cancer NCI Pooling Project 58 Interval Cancers
Finding Polyps
Rex; CGH 2010; 8: 318-21 Improving Detection: Looking behind folds Looking behind folds Recent Literature Result 3 rd eye 11% gain Retroflexion colonoscopy Omni-vision Cap-assisted Hewitt; DDW 2010 Transparent retractable extension device Horiuchi; CGH 2010; 8:379 360 degree view 31% increase in ADR Most < 5mm
Hewitt; DDW 2010 Improving Polyp Detection: Cap-fitted Colonoscopy n Adenoma(s) Miss rate >6mm Cap-Fitted 53 35 (66%) No Dif 23% Regular 47 32 (68%) 35% Miss rate <5mm Courtesy of Dr. Hewitt
Rex; CGH 2010; 8: 318-21 Innovations in colonoscopy: Detecting more polyps Finding more polyps High-Definition White light (HDWL) Recent Literature Buchner; CGH 2010;8:364 Result Slightly higher ADR
Rex; CGH 2010; 8: 318-21 Innovations in colonoscopy: Detecting more polyps Finding more polyps Recent Literature Result NBI Horiuchi; CGH 2010; 8:379 No significant ADR increase 6 RCT s: 5 negative
Rex; CGH 2010; 8: 318-21 Innovations in colonoscopy: Detecting more polyps Finding more polyps Recent Literature Result Autofluorescence DDW 2010 Mixed Results FICE ( Fuji intelligent chromoendoscopy) Pohl; GUT 2009; 58: 73 (-) study
Leggett and Whitehall; Gastro 2010;138: 2088-2100 Serrated Polyps Proximal Pathway may account for up to 20% of CRC Genetic pathways are partially characterized Normal function: Induces senesence CpG island Methylation: Silence MLH1 Sessile Serrated Polyp
Lambert et al; GIE 2009; 70: 1182-99 Sessile Serrated Lesion
Rex; CGH 2010; 8: 318-21 Innovations in colonoscopy: Finding more polyps High-Definition White light (HDWL) Result Adenoma detection rate (ADR) Slightly improved ADR NBI 6 RCTs: 5 (-) Chromoendoscopy FICE (Fuji intelligent chromo endoscopy) Autofluorescence I-Scan (digital chromoendoscopy) Technique may trump gadgets Increase small polyp detection (-) Mixed results?? GI FELLOW ++ VIDEO ++
Removing Polyps Completely
Robertson, Lieberman, Winawer; DDW 2008 Interval Cancer NCI Pooling Project 58 Interval Cancers
Rex; CGH 2010; 8: 318-21 Innovations in colonoscopy: Polyp Assessment Finding more polyps Recent Literature Result Chromoendoscopy Rex, 2006 Soetikno, 2008 1) Increase small polyp detection 2) Improve polyp assessment
Incomplete Polyp Removal
Incomplete Polyp Removal??
Serrated Polyp Huang;Am J Gastro 2011;106:229-240
Soetikno, JAMA 2008 Incomplete Polyp Removal Indigo-carmine Lessons: 1. Fully characterize the lesion 2. Not all polyps should be removed
Removing Polyps.Safely
Ko et al;abstract 2007; paper submitted Adverse events within 30 days of colonoscopy CORI Practice Sites (n = 18) 18, 271 patients with 30d f/u GI Bleed 1.53 Perforation 0.16 Other GI 0.38 Potentially related non-gi Angina/MI 0.66 Stroke/TIA 0.48 ALL Serious Events 3.34 Events/1000 procedures
Colonoscopy: Serious Adverse Events /1000 Setting Year n Bleed Perforation Other* Medicare; Claims data 30d f/u Community; Prospective Screening/Surv; 30d f/u 2009 53,220* 6.4 0.6 CV events with 7.0/1000 polypectomy 2010 21,375 1.59 0.19 1.31 3.34/1000 Warren et al; Ann Intern Med 2009; 150: 849-57 Ko, Lieberman; Clin Gastro Hep; 2010; 8: 166-73
Ko et al;abstract 2007; paper submitted Adverse events within 30 days of Risk Factors colonoscopy 18, 271 patients with 30d f/u Risk Factor Polypectomy with cautery > 1 polypectomy with cautery OR (95% CI) 2.31 (1.20,4.44) 3.99 (2.10,7.57) Pre-procedure warfarin 3.45 (1.66,7.22) Pre-procedure clopidogrel use 3.08 (1.10,8.67) Biopsy without cautery 0.30 (0.07,1.26) Polypectomy without cautery 1.37 (0.41,4.59)
Lessons 1. Older patients carefully balance risk and benefit 2. Anti-coagulation and clopidogrel are risk factors 3. Snare without cautery: LOWER RISK
Minimizing Harms of Colonoscopy: Orientation Polypectomy making it easier Torque to optimal position
Endoscopic Mucosal Resection (EMR) Standard Inject and Cut EMR (Saline assisted polypectomy) Soetikno et al. GIE 2003
Minimizing Harms of Colonoscopy: Be Prepared Bleeding : #1 GI complication of polypectomy Thick Stalk: consider epinephrine injection Have toys ready: Clips Loops Injection
Minimizing Harms of Colonoscopy Not all polyps should be removed Assess likelihood of incomplete removal Large, flat, carpeting polyps Non-lift with saline injection Possibly higher risk: Large cecal lesions
Minimizing Harms of Colonoscopy An incomplete colon is NOT always a failure Cecum
How can we improve colonoscopy?
Improving Colonoscopy Find important pathology Prep Meticulous withdrawal technique Assess important pathology Chromo-endoscopy for flat lesions Remove important pathology Prevent interval cancer Safely