Society for Gastrointestinal Endoscopy, was employed to list consecutive adenomatous polyps resected from the colon by snare cautery in 1989 to 1990. A total of99 polyps resected from 97 patients was reviewed. If the cauterized resection site could be identified and sections existed to show the clear relation of the resection to the stalk and head of the polyp, the polyp was considered adequately mounted and sectioned. Of the 99 polyps, 88 were appropriately mounted and sectioned and 11 were not. Seven polyps removed in fragments due to large size were treated as appropriately mounted. Of the 88 appropriately mounted polyps, eight cut through neoplastic tissue at the resection line. Adenoma was present in these. All 7 of the polyps removed in fragments and 5 of the 11 inadequately mounted and sectioned polyps had normal tissue on all sides of the cautery line indicating adequate removal. We conclude that we have not sufficiently emphasized completeness of resection in our training program for polyp removal and that the cutting and mounting of polyps can be modified to improve clinical-histological correlations. N. Haroon, D. M. Kruss, G. Chejfec, F. L. Iber,
MD MD MD MD
Departments of Gastroenterology and Pathology Edward Hines Veterans Administration Hospital and Loyola University Hines, Illinois
REFERENCES 1. Wolff WE, Shinya H. Polypectomy via the fiberoptic colono-
scope: removal of lesions beyond reach of the sigmoidoscope. N Engl J Med 1973;288:329-32. 2. OBrien MJ, Winawer SJ, Zauber AG, et al. The National Polyp Study. Patient and polyp characteristics associated with highgrade dysplasia in colorectal adenomas. Gastroenterology 1990; 98:371-9. 3. Cranley JP, Petras RE, Carey WD, Paradis K, Sivak MV. When is endoscopic polypectomy adequate therapy for colonic polyps containing invasive carcinoma? Gastroenterology 1986; 91:419-27. 4. Haggitt RC, Glotzbach RE, Soffer EE, Wruble LD. Prognostic factors in colorectal carcinomas arising in adenomas: implications for lesions removed by endoscopic polypectomy. Gastroenterology 1985;89:328-36.
Comparison of endoscopic Nd:YAG laser therapy and oesophageal tube in palliation or oesophagogastric malignancy HAHL
J,
SALO
J,
OVASKA
J,
ET AL.
Scand J Gastroenterol1991;26:103-8
The authors report a retrospective evaluation of 96 patients with upper gastrointestinal malignancy. Sixty-nine patients were treated with endoscopic laser therapy and 27 patients with insertion of an esophageal tube. After laser therapy, tumor bulk was reduced in 87% and dysphagia relieved in 55%. The insertion of an esophageal tube was successful in 89%. In the laser group, no fatal complications occurred. The overall complication rate was 8.7% and the I-year survival 12%. In the esophageal tube group, there was an 11 % mortality. The complications rate was 48% and the 1 year survival 0%. The authors conclude that both methods are effective in the palliation of esophagogastric malignancy but that the mortality and risk for complications were lower after laser therapy. This retrospective study compares two accepted techniques for palliation of esophagogastric tumors. Unfortunately, the study was not randomized nor were the two techniques being performed at the same period of time. The patients who had an esophageal tube inserted had in general more severe disease (100% endoscopically impassable lesions versus 50% in the laser group). The technique in the former was also suboptimal in that no radiological screening was used to insert the tube and in eight patients a laparotomy was required which is not the usual experience of most groups. The complication rate with tube insertion was high, but this now seems to be the general experience. Because of this, we now routinely perform dilation with the Savary dilators on all tumor strictures for as long as is feasible (but not more frequently than one dilation per month) and only then do we insert an esophageal tube. This cuts down the time the tube remains in situ and reduces the complication rate. The success and the complication rates with laser therapy were similar to that in other series. From this study laser therapy would seem indicated where the stricture allows the endoscope to pass through, but where there is a high grade stricture, the results of either therapy were very similar each having its advantages and disadvantages.
Abstracts
BEN NOVIS
Kfar-Saba, Israel
ENDOSCOPY AROUND THE WORLD Editor for Abstracts, James Barthel, MD Panel of Reviewers John Baillie Jamie S. Barkin Stanley B. Benjamin Lawrence J. Brandt David R. Cave Masayuki A. Fujino Lionello Gandolfi David Y. Graham Seibi Kobayashi
VOLUME 38, NO.2, 1992
Glen A. Lehman Zdenek Maratka Steven A. McClave Giorgio Minoli Ben Novis John F. Reinus Walter L. Trudeau Richard A. Wright
Flexible sigmoidoscopy may be ineffective for secondary prevention of colorectal cancer in asymptomatic, average-risk men FOUTCH PG, MAl H, PARDY
K, ET AL.
Dig Dis Sci 1991;36:924-8
Foutch and colleagues report the results of a study of flexible sigmoidoscopy as a screening test for colorectal neoplasms in asymptomatic average-risk men. They performed flexible sigmoidoscopy followed by colonoscopy on 114 men over age 50 without symptoms or signs of colorectal cancer. Subjects were not 205
at increased risk of developing colorectal neoplasia and had not had prior barium enema or sigmoidoscopic examinations. Three patients in the study group had a malignant colonic neoplasm diagnosed at sigmoidoscopy; no other malignant tumors were identified by colonoscopy. Forty-seven (41 %) of the individuals evaluated had adenomatous polyps: 21 subjects (18%) had adenomas discovered at sigmoidoscopy and no further polyps identified at colonoscopy, 9 individuals (8%) had adenomatous polyps detected at sigmoidoscopy as well as additional lesions found proximally at colonoscopy, and 17 persons (15%) had a negative sigmoidoscopy but had proximal polyps discovered at colonoscopy. Of 84 patients with negative sigmoidoscopies, 17 (20%) had proximal colonic polyps identified at colonoscopy. Furthermore, of 47 subjects with adenomas, 17 (36%) only had lesions beyond the reach of the flexible sigmoidoscope; the majority of these polyps were small «1 em) tubular adenomas. A comparison of findings (polyp number, size, and histology) in patients with adenomatous polyps failed to reveal any feature which identified patients with proximal lesions in the absence of distal ones. The authors concluded that flexible sigmoidoscopy may be a poor screening test for colonic neoplasms in asymptomatic men. Flexible sigmoidoscopy for early detection of colorectal neoplasms in asymptomatic average-risk individuals has yet to be evaluated in a prospective randomized controlled study. Despite the absence of scientific data on which to base guidelines, the American Cancer Society, the International Workgroup on Colorectal Cancer, and the National Cancer Institute have recommended early cancer detection programs which include sigmoidoscopy every 3 to 5 years for individuals over age 50. In contrast, the Canadian Cancer Society and the United States Preventive Service Task Force have not endorsed sigmoidoscopy for cancer detection in the absence of symptoms. The recommendation of sigmoidoscopy for asymptomatic individuals over age 50 is predicted on the clinical importance of diagnosing colorectal neoplasms at a curable state, and the belief that sigmoidoscopy, particularly flexible sigmoidoscopy, is a safe and effective method of achieving this goal. The latter proposition can be validated only by demonstrating that screening sigmoidoscopy is responsible for a decline in both the annual incidence of colon cancer and the mortality rate from this disease. In this very interesting article, Foutch and colleagues do not assess flexible sigmoidoscopy as a method of early colorectal cancer detection by studying the effect of the procedure on clinical outcome. Instead, they report the number and location of benign and malignant colon neoplasms detected in asymptomatic men who have undergone both flexible sigmoidoscopy and colonoscopy. As expected, they have found benign colon lesions to be much more common than malignant ones, and they also have noted that many individuals with polyps of the proximal colon do not have any lesions in the distal colon, facts which may influence the outcome of prospective studies of sigmoidoscopy as a tool for the early diagnosis of colorectal neoplasms. 206
The type and location of colorectal neoplasms which occur in asymptomatic persons, as well as the ability of sigmoidoscopy to detect them accurately, were important considerations in the original choice of this procedure for use in cancer detection. Numerous epidemiological studies based on colonoscopic examinations, as well as surgical and autopsy material, have established the prevalence and distribution of colon polyps in various population groups. Age has been found to be the most important determinant of adenoma prevalence: approximately 50% in asymptomatic Americans over age 60. Surgical and colonoscopic studies are responsible for the impression that most colon polyps are found in the distal colon and rectum, within reach of the sigmoidoscope, while autopsy series demonstrate a more even distribution of these lesions throughout the colon. Flexible sigmoidoscopy previously has identified polyps in 10 to 15% of asymptomatic individuals over age 40. It remains to be shown that finding and removing neoplasms before they cause symptoms reduces the number of persons who develop colorectal cancer and increases the identification of early lesions in relation to the overall number of cancers diagnosed. Finally, to be of value as a method of early cancer detection, screening sigmoidoscopy must reduce the mortality from colorectal cancer. Once the ability of sigmoidoscopy to accomplish these goals has been established, the social issue of whether the proven result justified the costs of performing the test can be addressed by appropriate measures. In the meantime, it can be argued that the original logic which prompted the American Cancer Society and other organizations to recommend sigmoidoscopic examinations for all persons over age 50 still pertains. GREGORY SOLOWAY JOHN
F.
REINUS
Bronx, New York
Study of small colorectal polyps and early cancers IGARASHI M, KATSUMATA T, Dig Endosc 1991;3:443-51
KOBAYASHI K, ET AL.
The authors investigated the histopathological features of polyps with diameters of less than 5 mm resected by snare or hot biopsy from 712 patients. A total of 1357 small polyps were removed and studied: 67.7% of the polyps were adenomas, 15.5% were metaplastic polyps, 0.6% were colon cancers, and 0.1 % were carcinoids. Eighty percent of the polyps situated proximal to the descending colon were adenomas. Although adenomas occurred somewhat more frequently in the sigmoid colon, they tended to be distributed evenly throughout the entire colon. Adenomas tended to have a red surface color, while metaplastic polyps were more likely to be associated with a white surface color. Multiple polyps occurred in 57% of the patients. Large polyps with diameters more than 6 mm were present in 33.7% of the patients. In six of the eight cancer cases, the cancers were limited to the mucosa. Cancer invading the submucosa was present in the other two cases. One of these cases was a depressed type of cancer and the other lesion was GASTROINTESTINAL ENDOSCOPY
MD MD MD MD
Departments of Gastroenterology and Pathology Edward Hines Veterans Administration Hospital and Loyola University Hines, Illinois
REFERENCES 1. Wolff WE, Shinya H. Polypectomy via the fiberoptic colono-
scope: removal of lesions beyond reach of the sigmoidoscope. N Engl J Med 1973;288:329-32. 2. OBrien MJ, Winawer SJ, Zauber AG, et al. The National Polyp Study. Patient and polyp characteristics associated with highgrade dysplasia in colorectal adenomas. Gastroenterology 1990; 98:371-9. 3. Cranley JP, Petras RE, Carey WD, Paradis K, Sivak MV. When is endoscopic polypectomy adequate therapy for colonic polyps containing invasive carcinoma? Gastroenterology 1986; 91:419-27. 4. Haggitt RC, Glotzbach RE, Soffer EE, Wruble LD. Prognostic factors in colorectal carcinomas arising in adenomas: implications for lesions removed by endoscopic polypectomy. Gastroenterology 1985;89:328-36.
Comparison of endoscopic Nd:YAG laser therapy and oesophageal tube in palliation or oesophagogastric malignancy HAHL
J,
SALO
J,
OVASKA
J,
ET AL.
Scand J Gastroenterol1991;26:103-8
The authors report a retrospective evaluation of 96 patients with upper gastrointestinal malignancy. Sixty-nine patients were treated with endoscopic laser therapy and 27 patients with insertion of an esophageal tube. After laser therapy, tumor bulk was reduced in 87% and dysphagia relieved in 55%. The insertion of an esophageal tube was successful in 89%. In the laser group, no fatal complications occurred. The overall complication rate was 8.7% and the I-year survival 12%. In the esophageal tube group, there was an 11 % mortality. The complications rate was 48% and the 1 year survival 0%. The authors conclude that both methods are effective in the palliation of esophagogastric malignancy but that the mortality and risk for complications were lower after laser therapy. This retrospective study compares two accepted techniques for palliation of esophagogastric tumors. Unfortunately, the study was not randomized nor were the two techniques being performed at the same period of time. The patients who had an esophageal tube inserted had in general more severe disease (100% endoscopically impassable lesions versus 50% in the laser group). The technique in the former was also suboptimal in that no radiological screening was used to insert the tube and in eight patients a laparotomy was required which is not the usual experience of most groups. The complication rate with tube insertion was high, but this now seems to be the general experience. Because of this, we now routinely perform dilation with the Savary dilators on all tumor strictures for as long as is feasible (but not more frequently than one dilation per month) and only then do we insert an esophageal tube. This cuts down the time the tube remains in situ and reduces the complication rate. The success and the complication rates with laser therapy were similar to that in other series. From this study laser therapy would seem indicated where the stricture allows the endoscope to pass through, but where there is a high grade stricture, the results of either therapy were very similar each having its advantages and disadvantages.
Abstracts
BEN NOVIS
Kfar-Saba, Israel
ENDOSCOPY AROUND THE WORLD Editor for Abstracts, James Barthel, MD Panel of Reviewers John Baillie Jamie S. Barkin Stanley B. Benjamin Lawrence J. Brandt David R. Cave Masayuki A. Fujino Lionello Gandolfi David Y. Graham Seibi Kobayashi
VOLUME 38, NO.2, 1992
Glen A. Lehman Zdenek Maratka Steven A. McClave Giorgio Minoli Ben Novis John F. Reinus Walter L. Trudeau Richard A. Wright
Flexible sigmoidoscopy may be ineffective for secondary prevention of colorectal cancer in asymptomatic, average-risk men FOUTCH PG, MAl H, PARDY
K, ET AL.
Dig Dis Sci 1991;36:924-8
Foutch and colleagues report the results of a study of flexible sigmoidoscopy as a screening test for colorectal neoplasms in asymptomatic average-risk men. They performed flexible sigmoidoscopy followed by colonoscopy on 114 men over age 50 without symptoms or signs of colorectal cancer. Subjects were not 205
at increased risk of developing colorectal neoplasia and had not had prior barium enema or sigmoidoscopic examinations. Three patients in the study group had a malignant colonic neoplasm diagnosed at sigmoidoscopy; no other malignant tumors were identified by colonoscopy. Forty-seven (41 %) of the individuals evaluated had adenomatous polyps: 21 subjects (18%) had adenomas discovered at sigmoidoscopy and no further polyps identified at colonoscopy, 9 individuals (8%) had adenomatous polyps detected at sigmoidoscopy as well as additional lesions found proximally at colonoscopy, and 17 persons (15%) had a negative sigmoidoscopy but had proximal polyps discovered at colonoscopy. Of 84 patients with negative sigmoidoscopies, 17 (20%) had proximal colonic polyps identified at colonoscopy. Furthermore, of 47 subjects with adenomas, 17 (36%) only had lesions beyond the reach of the flexible sigmoidoscope; the majority of these polyps were small «1 em) tubular adenomas. A comparison of findings (polyp number, size, and histology) in patients with adenomatous polyps failed to reveal any feature which identified patients with proximal lesions in the absence of distal ones. The authors concluded that flexible sigmoidoscopy may be a poor screening test for colonic neoplasms in asymptomatic men. Flexible sigmoidoscopy for early detection of colorectal neoplasms in asymptomatic average-risk individuals has yet to be evaluated in a prospective randomized controlled study. Despite the absence of scientific data on which to base guidelines, the American Cancer Society, the International Workgroup on Colorectal Cancer, and the National Cancer Institute have recommended early cancer detection programs which include sigmoidoscopy every 3 to 5 years for individuals over age 50. In contrast, the Canadian Cancer Society and the United States Preventive Service Task Force have not endorsed sigmoidoscopy for cancer detection in the absence of symptoms. The recommendation of sigmoidoscopy for asymptomatic individuals over age 50 is predicted on the clinical importance of diagnosing colorectal neoplasms at a curable state, and the belief that sigmoidoscopy, particularly flexible sigmoidoscopy, is a safe and effective method of achieving this goal. The latter proposition can be validated only by demonstrating that screening sigmoidoscopy is responsible for a decline in both the annual incidence of colon cancer and the mortality rate from this disease. In this very interesting article, Foutch and colleagues do not assess flexible sigmoidoscopy as a method of early colorectal cancer detection by studying the effect of the procedure on clinical outcome. Instead, they report the number and location of benign and malignant colon neoplasms detected in asymptomatic men who have undergone both flexible sigmoidoscopy and colonoscopy. As expected, they have found benign colon lesions to be much more common than malignant ones, and they also have noted that many individuals with polyps of the proximal colon do not have any lesions in the distal colon, facts which may influence the outcome of prospective studies of sigmoidoscopy as a tool for the early diagnosis of colorectal neoplasms. 206
The type and location of colorectal neoplasms which occur in asymptomatic persons, as well as the ability of sigmoidoscopy to detect them accurately, were important considerations in the original choice of this procedure for use in cancer detection. Numerous epidemiological studies based on colonoscopic examinations, as well as surgical and autopsy material, have established the prevalence and distribution of colon polyps in various population groups. Age has been found to be the most important determinant of adenoma prevalence: approximately 50% in asymptomatic Americans over age 60. Surgical and colonoscopic studies are responsible for the impression that most colon polyps are found in the distal colon and rectum, within reach of the sigmoidoscope, while autopsy series demonstrate a more even distribution of these lesions throughout the colon. Flexible sigmoidoscopy previously has identified polyps in 10 to 15% of asymptomatic individuals over age 40. It remains to be shown that finding and removing neoplasms before they cause symptoms reduces the number of persons who develop colorectal cancer and increases the identification of early lesions in relation to the overall number of cancers diagnosed. Finally, to be of value as a method of early cancer detection, screening sigmoidoscopy must reduce the mortality from colorectal cancer. Once the ability of sigmoidoscopy to accomplish these goals has been established, the social issue of whether the proven result justified the costs of performing the test can be addressed by appropriate measures. In the meantime, it can be argued that the original logic which prompted the American Cancer Society and other organizations to recommend sigmoidoscopic examinations for all persons over age 50 still pertains. GREGORY SOLOWAY JOHN
F.
REINUS
Bronx, New York
Study of small colorectal polyps and early cancers IGARASHI M, KATSUMATA T, Dig Endosc 1991;3:443-51
KOBAYASHI K, ET AL.
The authors investigated the histopathological features of polyps with diameters of less than 5 mm resected by snare or hot biopsy from 712 patients. A total of 1357 small polyps were removed and studied: 67.7% of the polyps were adenomas, 15.5% were metaplastic polyps, 0.6% were colon cancers, and 0.1 % were carcinoids. Eighty percent of the polyps situated proximal to the descending colon were adenomas. Although adenomas occurred somewhat more frequently in the sigmoid colon, they tended to be distributed evenly throughout the entire colon. Adenomas tended to have a red surface color, while metaplastic polyps were more likely to be associated with a white surface color. Multiple polyps occurred in 57% of the patients. Large polyps with diameters more than 6 mm were present in 33.7% of the patients. In six of the eight cancer cases, the cancers were limited to the mucosa. Cancer invading the submucosa was present in the other two cases. One of these cases was a depressed type of cancer and the other lesion was GASTROINTESTINAL ENDOSCOPY
