Search

Background Recent evidence suggests that the number of low residue diet (LRD) days does not influence the bowel cleansing quality in non-selected patients. However, there are not data in the subgroup of patients with risk factors of inadequate bowel cleansing. Objective The aim of this study was to assess whether a 3-day LRD improved the bowel cleansing quality in patients with risk factors of poor bowel cleansing. Patients and methods Post hoc analysis of a randomized controlled trial carried out between December 2017 and March 2018 in a tertiary care hospital. Patients with high risk of poor bowel cleansing were selected following a validated score. The patients were randomized to the 1-day LRD or 3-day LRD groups. All patients received a 2-L split-dose of polyethylene glycol plus ascorbic acid. Intention-to-treat (ITT) and per-protocol (PP) analyses were conducted for the main outcome. Results 135 patients (1-day LRD group = 67, 3-day LRD = 68) were included. The rate of adequate cleansing quality was not significantly different between the groups in the ITT analysis: 76.1%, 95% CI: [64.6–84.8] vs. 79.4%, 95% CI: [68.2–87.4]; odds ratio (OR) 1.2, 95% CI [0.54–2.73]) or in the PP analysis: 77.3%, 95% CI: [65.7–85.8] vs. 80.3%, 95% CI: [69.0–88.3]; OR 1.2, 95% CI [0.52–2.77]). Compliance with the diet or cleansing solution, satisfaction or difficulties with the LRD and the polyp/adenoma detection rates were not significantly different. Conclusion Our results suggest that 1-day LRD is not inferior to 3-day LRD in patients with risk factors of inadequate bowel cleansing.

Matrix metalloproteinases (MMPs) are overexpressed at different stages of colorectal carcinogenesis and could serve as early surrogate biomarkers of colorectal neoplasia.To assess the utility of plasma MMP2 and MMP9 levels in the detection of advanced colorectal neoplasia and their correlation with tissue levels.We analysed blood and tissue samples from patients with non-advanced adenomas (n=25), advanced adenomas (n=25), colorectal cancer (n=25) and healthy controls (n=75). Plasma and tissue gelatinase levels were determined by Luminex XMAP technology and gelatin zymography. Receiver operating characteristic (ROC) curve analysis was used to calculate the optimum cut-off for the detection of advanced colorectal neoplasia.Plasma MMP2 levels were similar between groups whatever the type of lesion. Plasma MMP9 levels were significantly higher in patients with neoplastic lesions than in healthy controls (median 292.3ng/ml vs. 139.08ng/ml, P0.001). MMP9 levels were also higher in colorectal cancer than in non-advanced adenomas (median 314.6ng/ml vs. 274.3ng/ml, P=0.03). There was a significant correlation between plasma and tissue levels of MMP9 (r=0.5, P0.001). The plasma MMP9 cut-off range with the highest diagnostic accuracy was between 173ng/ml and 204ng/ml (AUC=0.80 [95% CI: 0.72-0.86], P0.001; sensitivity, 80-86% and specificity, 57-67%).Plasma MMP9 could be a surrogate biomarker for the early detection of advanced colorectal neoplasia, although its diagnostic performance could be increased by combination with other biomarkers.

First-degree relatives of patients with colorectal cancer (CRC) are at high risk of this disease. For this reason, medical organizations and clinical guidelines recommend more intensive screening and surveillance for such first-degree relatives than for the average-risk population. Colonoscopy has been the cornerstone of CRC screening in this setting. Although colonoscopy is the most sensitive technique for the detection of neoplastic lesions (especially non-advanced adenomas), its role is less clear for CRC. In addition, screening colonoscopy has several limitations that may affect the success of a screening campaign, such as poor participant acceptance, the need for skilled endoscopists, participant access to screening colonoscopy, overburdened endoscopy units, potential complications, and procedure-related costs. In addition, recent evidence has cast doubt on the advantage of colonoscopy over other strategies for the detection of advanced neoplastic lesions. Despite being less sensitive in general, other screening methods frequently recommended in the average-risk population may be more acceptable and thus help increase CRC screening uptake. This review discusses recent evidence on the risk of CRC in first-degree relatives, the advantages and disadvantages of each screening technique, participation rates depending on the technique, patient preferences, and barriers to screening.

BackgroundDifferentiation between benign and malignant portal vein thrombosis (PVT) in the setting of a hepatocellular carcinoma (HCC) is of paramount importance. Histological analysis is usually not carried out because of potential severe side effects of the percutaneous approach. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) may be safer and may guide the clinical management of patients with HCC.ObjectiveTo describe the feasibility of the EUS-FNA in a series of patients with HCC and PVT.Materials and methodsA chart review of patients with PVT was performed from 2014 to 2016 in three tertiary care hospitals of Spain. Patients with chronic liver disease and PVT with a suspicion of HCC referred for EUS-FNA were included. The impact of the EUS-FNA was assessed by comparing staging following the Barcelona Clinic Liver Cancer algorithm (BCLC) before and after EUS-FNA.ResultsOf 104 patients with PVT and chronic liver disease, 23 were considered candidates for EUS-FNA. Eight patients were referred for EUS-FNA. The technique was feasible in seven patients and FNA was positive in six patients. No side effects were reported. EUS-FNA upstaged six out of seven (85.7%) patients: one patient BCLC stage B, two patients BCLC stage A, and three patients in whom the HCC was not diagnosed before EUS-FNA of the PVT. A benign PVT was found in the explant of the only patient with a negative PVT.ConclusionEUS-FNA is a valuable technique in selected patients with chronic liver disease with PVT. It is feasible, safe, and may alter the clinical management in these patients.

The aim of the present study was to perform a comparative cost-effectiveness analysis of the different strategies used to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) acute pancreatitis.We performed a cost-effectiveness decision analysis of 4 prophylactic strategies (nonsteroidal anti-inflammatory drugs or NSAIDs, pancreatic stent, stent plus rectal indomethacin, and no prophylaxis) in a simulated cohort of 300 patients during 1 year. Treatment effectiveness was defined as the number of patients who did not develop post-ERCP pancreatitis.The baseline costs of each strategy were as follows: rectal NSAID $359,098, pancreatic stent $426,504, stent plus rectal indomethacin $479,153, and no prophylaxis $491,275. The mean number of cases developing post-ERCP pancreatitis was 16, 21, 23, and 37 for the strategies rectal NSAID, pancreatic stent, stent plus rectal indomethacin, and no prophylaxis, respectively. Taking rectal NSAID prophylaxis as the reference strategy, the odds ratio of an episode of post-ERCP acute pancreatitis after pancreatic stent placement was 1.33 (95% confidence interval [CI], 0.68-2.61); after stent plus indomethacin, it was 1.40 (95% CI, 0.72-2.73), and after no prophylaxis, it was 2.49 (95% CI, 1.35-4.59).Rectal NSAID administration proved to be the most cost-effective prophylactic strategy used to prevent post-ERCP pancreatitis. The strategy of no prophylaxis for this complication should be avoided.

Background Standard bowel cleansing for colon capsule endoscopy (CCE) requires a liquid diet and bowel laxatives for at least 2 days, which is a major drawback of this procedure and affects tolerance and acceptability. Objective To compare the quality of colon cleanliness achieved with one-day versus two-day bowel preparation in outpatients undergoing CCE. Methods Patients were randomly assigned to one of two groups: group I (one-day schedule, n = 20) received a fiber-free diet and 3 L of polyethylene glycol (PEG) on day 0; group II (two-day schedule, n = 20) received a liquid diet and 3 L of PEG in the evening of day −1, and 1 L of PEG in the early morning of day 0. In both groups, the patients received 15 mg bisacodyl on day −1 and one or two additional sodium phosphate (NaP) boosters following capsule ingestion. Each colon segment was assessed for cleanliness using a four-point grading scale (excellent = 1, good = 2, fair = 3, and poor = 4). For the final analysis, colon cleanliness was rated as adequate (good or excellent) or inadequate (fair or poor). Results Overall colon cleanliness was adequate in 94% (CI 91–97) of patients in group I versus 80% (CI 72–88) in group II ( P = 0.27). No significant differences were observed in the per-segment quality of colon cleansing between the two groups. CCE reached the rectum in 80% (CI 73–87) of patients in group I versus 75% (CI 67–83) in group II (p = 0.59). Conclusion The quality of colon cleanliness achieved with one-day bowel preparation is equivalent to that of the standard two-day schedule in patients undergoing CCE.

Colonoscopy is the recommended method for diagnosis of colorectal diseases but the number of neoplastic lesions missed is not negligible. To reduce this it is necessary to achieve quality standards in colonoscopy, for example the extent of cecal intubation, adequate bowel cleansing, and appropriate withdrawal time. Conventional wisdom is that proper colonoscopy training is the most important aspect of detection of subtle lesions. Systematic examination, including careful inspection behind folds, removal of residual stools by lavage, and awareness of and an active search for subtle mucosal abnormalities, are key factors in increasing detection of neoplastic lesions. In addition, ancillary techniques might aid detection or better characterization of additional lesions. This review focuses on the requirements for a high quality colonoscopy and on the novel techniques that may improve detection of adenoma.

Background & Aims We investigated whether patients with multiple serrated polyps, but not meeting the World Health Organization criteria for serrated polyposis syndrome, and their relatives have similar risks for colorectal cancer (CRC) as those diagnosed with serrated polyposis. Methods We collected data from patients with more than 10 colonic polyps, recruited in 2008–2009 from 24 hospitals in Spain for a study of causes of multiple colonic polyps. We analyzed data from 53 patients who met the criteria for serrated polyposis and 145 patients who did not meet these criteria, but who had more than 10 polyps throughout the colon, of which more than 50% were serrated. We calculated age- and sex-adjusted standardized incidence ratios (SIRs) for CRC in both groups, as well as in their first-degree relatives. Results The prevalence of CRC was similar between patients with confirmed serrated polyposis and multiple serrated polyps (odds ratio, 1.35; 95% confidence interval [CI], 0.64–2.82; P = .40). The SIR for CRC in patients with serrated polyposis (0.51; 95% CI, 0.01–2.82) did not differ significantly from the SIR for CRC in patients with multiple serrated polyps (0.74; 95% CI, 0.20–1.90; P = .70). The SIR for CRC also did not differ significantly between first-degree relatives of these groups (serrated polyposis: 3.28, 95% CI, 2.16–4.77; multiple serrated polyps: 2.79, 95% CI, 2.10–3.63; P = .50). Kaplan–Meier analysis showed no differences in the incidence of CRC between groups during the follow-up period (log-rank, 0.6). Conclusions The risk of CRC in patients with multiple serrated polyps who do not meet the criteria for serrated polyposis, and in their first-degree relatives, is similar to that of patients diagnosed with serrated polyposis.

Inadequate bowel cleansing is a major burden for endoscopy units. The aim of this study was to compare two intensive bowel cleansing regimens in patients with previous colonoscopy with inadequate bowel preparation.Patients with inadequate cleansing at index colonoscopy were randomized to 4-L split-dose polyethylene-glycol (PEG) regimen vs. 2-L split-dose PEG plus ascorbic acid (PEG+Asc) regimen. All individuals underwent a 3-day low-residue diet and received 10 mg of bisacodyl, the day before colonoscopy. Cleansing was considered to be adequate if the Boston Bowel Preparation Scale scored ≥2 at each colonic segment. A non-inferiority analysis was performed to demonstrate that colonic cleansing with 2-L PEG+Asc was not inferior to 4-l PEG, considering a non-inferiority margin of 10%.Adequate bowel cleansing was significantly higher in patients assigned to 4-L PEG regimen (n=127) vs. those randomized to 2-L PEG+Asc regimen (n=129) by intention-to-treat analysis (81.1 vs. 67.4%, odds ratio (OR) 2.07, 95% confidence interval (CI) (1.163-3.689)) and by per-protocol analysis (86.6 vs. 71.7%, OR: 2.55, 95% CI: (1.316-4.922)). The study was terminated for futility after the interim analysis, because the 95% CI of the difference of proportions was 3.13-24.27% in the intention-to-treat analysis and 3.33-26.47% in the per-protocol analysis, confirming the superiority of 4-L PEG preparation.After 3-day low-residue diet and oral bisacodyl before colonoscopy, colon cleansing with 4-L split-dose PEG was superior to 2-L split-dose PEG+Asc in patients with previous inadequate cleansing. (EUDRACT: 2013-002506-31, NCT02073552).

Resumen La diseccion submucosa endoscopica (DSE) es una tecnica terapeutica endoscopica aplicable a las neoplasias digestivas precoces y desarrollada con los objetivos de conseguir una reseccion radical curativa y una disminucion de las intervenciones quirurgicas innecesarias. Disenada en los paises orientales, se encuentra poco extendida en Occidente. Aunque la DSE representa un avance terapeutico endoscopico significativo y persigue la curacion completa del paciente, ofrece en contrapartida una mayor incidencia de complicaciones (hemorragia, perforacion) que obligan a la adquisicion de una destreza tecnica y experiencia mediante un programa de entrenamiento estructurado y progresivo con el fin de disminuir la morbilidad asociada a esta tecnica e incrementar los beneficios potenciales de la misma. Aunque se ha publicado una importante evidencia cientifica sobre sus aplicaciones y resultados, las publicaciones relacionadas con su ensenanza son escasas y no hay un programa estandarizado de aprendizaje. El autor ha tratado de describir las diversas propuestas de entrenamiento pero tambien los principios basicos de la tecnica, sus indicaciones y los resultados obtenidos, ya que antes del aprendizaje es conveniente disponer de una base teorica de conocimiento que permita guiar al endoscopista durante la aplicacion clinica de esta tecnica endoscopica. El adiestramiento en una tecnica endoscopica no sirve de nada si no se conoce para que se emplea, en que situaciones se debe aplicar y que resultados se debe esperar de ella.

Resumen Introduccion Internet ha supuesto un cambio radical en el acceso a la informacion medica. No se ha estudiado el acceso a webs medicas en los pacientes con enfermedades digestivas en nuestro medio. Objetivo Determinar el nivel de acceso y el uso de Internet como fuente de informacion medica de los pacientes con enfermedades digestivas en nuestro entorno. Material y metodos Se encuestaron 699 pacientes consecutivos, ingresados y de consultas externas intra y extrahospitalarias de Digestivo. Resultados Respondieron 671 pacientes (55% mujeres), rango de edad 18 a 88 anos, media de 54 + 16. Usaban Internet el 36%. No hubo diferencias por sexos, pero si por edad (86% los mayores de 30 anos vs 6% los mayores de 70, p 0,005, OR 2,710 IC 1,628-4,511). La informacion le parecio menos fiable que la del medico al 77% de los hombres y al 70% de las mujeres. Al 86% le gustaria usar el correo electronico con su medico. El 89% consideraban Internet util para resolver dudas, el 89% querian direcciones de salud y el 90% informacion periodica sobre su enfermedad. Los pacientes no universitarios demandaban mas informacion periodica (p = 0,01) y sobre como buscar informacion medica (p = 0,03). Conclusiones Una tercera parte de los pacientes con enfermedades digestivas utilizan Internet para informarse acerca de su enfermedad. Los pacientes quieren mayor informacion de su medico sobre recursos de salud en Internet.

Background & Aims 5-Fluorouracil (5-FU)–based adjuvant chemotherapy does not increase survival times of patients with colorectal tumors with microsatellite instability. We determined the response of patients with colorectal tumors with the CpG island methylator phenotype (CIMP) to 5-FU–based therapy. Methods We analyzed a population-based cohort of 302 patients with colorectal cancer (CRC) for a median follow-up time of 50.7 months. CIMP status was determined by analysis of the CACNAG1 , SOCS1 , RUNX3 , NEUROG1 , and MLH1 promoters; tumors were considered to be CIMP positive if at least 3 promoters were methylated. Results Tumors from 29.5% of patients (89/302) were CIMP positive; CIMP status did not influence disease-free survival (DFS; log-rank = 0.3). Of tumors of TNM stages II–III (n = 196), 32.7% were CIMP positive. Among patients with stages II–III CRC who did not receive adjuvant 5-FU chemotherapy, those with CIMP-positive tumors had longest times of DFS (log-rank = 0.04); In patients who received chemotherapy, those with CIMP-positive tumors had shorter times of DFS (log-rank = 0.02). In patients with CIMP-negative tumors, adjuvant 5-FU chemotherapy significantly increased time of DFS (log-rank = 0.00001). However, in patients with CIMP-positive tumors, adjuvant 5-FU chemotherapy did not affect time of DFS (log-rank = 0.7). Multivariate analysis showed a significant, independent interaction between 5-FU treatment and CIMP status (hazard ratio [HR], 0.6; 95% confidence interval [CI], 0.5–0.8). Among patients with CIMP-positive tumors, adjuvant chemotherapy was not an independent predictor of outcome (HR, 0.8; 95% CI, 0.3–2.0). In patients who did not receive adjuvant 5-FU chemotherapy, CIMP status was the only independent predictor of survival (HR, 2.0; 95% CI, 1.1–3.8). Conclusions Patients with CIMP-positive colorectal tumors do not benefit from 5-FU–based adjuvant chemotherapy.

Although primary pancreatic lymphoma (PPL) is a rare malignant tumor, the correct diagnosis is essential since their therapeutic management differs from other pancreatic tumors. The fine needle aspiration cytology guided by endoscopic ultrasonography (EUS-FNA) is currently the preferred technique for the diagnosis of neoplasms of the pancreas, being of particular interest in those pancreatic lesions with atypical characteristics or presentation. However, the usefulness of EUS-FNA in the PPL has been poorly studied because of the rarity of this entity. We report a case of a patient with HIV infection and PPL diagnosed by EUS-FNA.

Colonoscopy is empirically recommended as the first choice screening strategy in first-degree relatives of patients with colorectal cancer (CRC). However, this strategy is accepted by less than 40% of the risk population and two-thirds of screened individuals and renders a normal exploration. This pilot study assessed the accuracy of a latex agglutination immunochemical fecal occult blood test (LA-FOBT) for detecting advanced colorectal neoplasm (cancer or adenomatous polypsor =1 cm in size, with villous pattern or high grade dysplasia) in asymptomatic first-degree relatives of patients with CRC.One hundred and sixty-nine first-degree relatives of 135 index cases were prospectively included. All participants received a sensitive LA-FOBT (hemoglobin detection limit of 50 ng/ml buffer), and were invited to undergo colonoscopy. On the whole, 116 (69%) participants returned LA-FOBT and underwent colonoscopy.LA-FOBT was positive in 19 of 116 (16%) cases. Colonoscopy detected neoplasms in 49 of 116 (42%) patients: 37 of 116 (32%) were nonadvanced adenomas and 12 of 116 (10%) advanced adenomas. LA-FOBT detected 10 of 12 (83%) advanced adenomas showing a sensitivity, specificity, positive predictive value, and negative predictive value of 83, 91, 53, and 98%, respectively. In patients with positive LA-FOBT, 1.9 colonoscopies were necessary for detecting one advanced adenoma, whereas in case of not performing this test 10 colonoscopies would be needed. Overall, approximately 80% of screening colonoscopies could be precluded using a LA-FOBT.One-time screening with LA-FOBT successfully detects advanced colorectal adenomas and may save unnecessary colonoscopies in first-degree relatives of patients with CRC.

to determine the frequency and malignancy risk of colonic flat adenomas among patients with colorectal polyps in a Spanish population.1300 consecutive colonoscopic examinations were reviewed; 640 polyps were detected and removed endoscopically in 298 patients. Chromoendoscopy with 0.2% indigo carmine was applied to clarify the macroscopical appearance of flat lesions. The following data was collected for flat and protruding polyps: size, location (proximal or distal to splenic flexure), histology (neoplastic or non neoplastic), high grade dysplasia (HGD) and submucosal invasive carcinoma (SIC) or beyond.490 polyps (76.6%) were adenomas and 150 (23.4%) hyperplastic; 114 (23.3%) adenomas were flat (3 flat-depressed) whereas 376 (76.7%) were protruding. The diameter of flat and protruding adenomas was 9.2 +/- 7.9. mm and 7.0 +/- 5.9 mm, respectively (p0.001). A proximal location was more frequent for flat (63.1%) than for protruding adenomas (48.7%) (p = 0.003). The rate of HGD or SIC was significantly higher in flat than in protruding adenomas (7.0 vs 2.6%; p0.04). Two of the 3 flat-depressed lesions (bothor= 10 mm in diameter) were carcinomas (T1 and T2, respectively). Flat adenomas had an increased risk for HGD or SIC (OR = 2,7; CI, 1,04-7,04; p0.05).In a Spanish population, flat adenomas represent nearly one quarter of all colorectal neoplastic polyps, their most frequent location being the right colon and they bear a higher risk of malignancy than protruding adenomas, especially for the flat depressed type.

Endoscopic ultrasonography-guided fine-needle aspiration cytology (EUS-FNA) may provide full-thickness biopsies, adequate for cytology and histology. In the present case report, we describe the first cases of a rare well-differentiated squamous esophageal carcinoma (verrucous esophageal cancer), finally diagnosed by EUS-FNA using a large FNA needle after several upper endoscopies with biopsies negative for malignancy. In this report, we highlight the usefulness of this procedure and EUS features in the diagnosis of suspicious esophageal lesions with negative endoscopic biopsies for malignancy.

Background & Aims: Colorectal cancers (CRCs) with microsatellite instability (MSI) and a mismatch repair (MMR) immunohistochemical deficit without hypermethylation of the MLH1 promoter are likely to be caused by Lynch syndrome. Some patients with these cancers have not been found to have pathogenic germline mutations and are considered to have Lynch-like syndrome (LLS). The aim of this study was to determine the risk of cancer in families of patients with LLS. Methods: We studied a population-based cohort of 1705 consecutive patients, performing MSI tests and immunohistochemical analyses of MMR proteins. Patients were diagnosed with Lynch syndrome when they were found to have pathogenic germline mutations. Patients with MSI and loss of MSH2 and/or MSH6 expression, isolated loss of PMS2 or loss of MLH1 without MLH1 promoter hypermethylation, and no pathogenic mutation were considered to have LLS. The clinical characteristics of patients and the age- and sex-adjusted standardized incidence ratios (SIRs) of cancer in families were compared between groups. Results: The incidence of CRC was significantly lower in families of patients with LLS than in families with confirmed cases of Lynch syndrome (SIR for Lynch syndrome, 6.04; 95% confidence interval [CI], 3.58–9.54; SIR for LLS, 2.12; 95% CI, 1.16–3.56; P < .001). However, the incidence of CRC was higher in families of patients with LLS than in families with sporadic CRC (SIR for sporadic CRC, 0.48; 95% CI, 0.27–0.79; P < .001). Conclusions: The risk of cancer in families with LLS is lower that of families with Lynch syndrome but higher than that of families with sporadic CRC. These results confirm the need for special screening and surveillance strategies for these patients and their relatives. This work was supported by grants from Instituto de Salud Carlos III (PI-080726, INT-09/208, and PI11/026030), the Fondo de Investigación Sanitaria/FEDER (PS09/02368, 10/00384, 10/00918, 11/00219, and 11/00681), Fundació Olga Torres (CRP) and FP7 CHIBCHA Consortium (SCB and ACar), the Ministerio de Economía y Competitividad (SAF2010-19273), and Agència de Gestió d’Ajuts Universitaris i de Recerca (2009 SGR 849). SCB is supported by a contract from the Fondo de Investigación Sanitaria (CP03-0070). CIBERER and CIBERehd are funded by the Instituto de Salud Carlos III.

Colon capsule endoscopy (CCE) is an orally ingested colon imaging tool used to evaluate patients with colonic disease. We evaluated the efficacy of CCE in helping physicians make decisions about patients with incomplete conventional colonoscopies (ICCs).In a prospective study, we analyzed data from 34 patients with nonocclusive ICC who were eligible for CCE between May 2010 and April 2011; patients with colectomy, occlusive lesions, or inadequate bowel cleansing for the colonoscopy were excluded. Two experienced observers who were blinded to colonoscopy findings analyzed the CCE data. Four months later, medical records were reviewed to determine the effects of CCE on medical decision making. CCE was considered conclusive when the findings facilitated a medical decision.Bowel cleanliness was good or excellent for 22 patients (64.7%). CCE exceeded the most proximal point reached by conventional colonoscopy in 29 patients (85.3%). CCE findings allowed formulation of a specific medical plan for 20 patients (58.8%); 12 (35.2%) had irrelevant or no lesions, so the study was concluded; 7 (20.5%) underwent polypectomy or surgery for advanced colorectal neoplasia; and 1 (3%) was treated for Crohn's disease. Inconclusive CCEs resulted from poor preparation of the bowel (n = 12) and excessively slow (n = 1) or rapid (n = 1) capsule transit.CCE might be an alternative procedure to complete colon examination in patients with nonocclusive ICC.

BACKGROUND It is well-established that the risk of postpolypectomy bleeding (PPB) increases with polyp size, but little is known about the factors that predict PPB in polyps larger than 10 mm. AIM The aim of this study is to assess the incidence and risk factors for PPB in colorectal polyps larger than 10 mm. METHODS A historical cohort study was carried out in an open access endoscopy unit from January 2007 to December 2008. Endoscopic polypectomy was performed in 1894 (28%) patients. Clinical records of patients with polyps of at least 10 mm were reviewed. Data on demographics, comorbidity, polyp-related features, and resection technique were collected. The incidence of immediate bleeding (during polypectomy) and delayed bleeding (up to 1 month later) was assessed. RESULTS A total of 424 large polyps (median size=12 mm; P₂₅-P₇₅: 10-16 mm) were resected. Thirty-five episodes of PPB occurred in 33 (7.8%) polyps, of which 12 (2.8%) were delayed. Multivariate logistic regression analysis demonstrated that a polyp size of at least 14 mm was the most important predictor of PPB [odds ratio (OR) 3.17, 95% confidence interval (CI) 1.492-6.751, P=0.003], compared with the presence of a villous architecture (OR 2.23, 95% CI 1.056-4.705, P=0.035) or high-grade dysplasia (OR 2.96, 95% CI 1.305-6.692, P=0.009). CONCLUSION In the current study, the rate of PPB was almost 8% in polyps larger than 10 mm, occurring in most cases during the endoscopic procedure. A polyp of size at least 14 mm was the most important predictor for PPB. Prospective studies are needed to determine whether preventive endoscopic therapy may reduce PPB in these patients.

Colorectal cancer (CRC) screening has been shown to reduce CRC incidence and mortality through the endoscopic detection and removal of colorectal adenomas. Still, these patients are at increased risk for developing metachronous adenomas or even cancer, with the recurrence rate reaching the 50%. The pleiotropic effects of higher levels of PGE2 contribute to key steps of cancer development, including cell proliferation, angiogenesis, invasiveness and migration, inhibition of apoptosis and immunosurveillance as a refletion of deregulation of ATP-binding cassete sub-family c member 4 (ABCC4) and solute carrier organic anion transporter family, member 2A1 (SLCO2A1) genes responsable for carrying PGE2 accross the membrane. To evaluate the influence of genetic polymorphisms in ABCC4 and SLCO2A1 on the risk and time for colorectal adenoma recurrence a retrospective case-cohort study was designed gathering 195 patients diagnosed with colorectal adenomas. Adenoma reccurence was defined has the diagnosis of an adenoma after a total normal colonoscopy at least one year after the initial diagnosis. Thirty-three tagSNPs were characterized using the MassARRAY iPLEX Gold technology based on multiplex amplification followed by mass-spectrometric product separation. Three tagSNPs were identified as susceptibility biomarkers for colorectal adenoma recurrence after a bootstrap analysis. The rs1131598GG homozygous genotype of SLCO2A1 gene was associated with an enhanced risk of 6.3 (95%CI:1.31-30.0, P=0.021). In contrast and under a dominant model of inheritance, the rs1751031 and rs9524821 polymorphisms in ABCC4 gene displayed a protective behaviour (OR=0.29, 95%CI:0.12-0.72, P=0.007 and OR=0.42, 95%CI:0.19-0.93, P=0.033, respectively). Furthermore, when stratifying patients considering the endoscopic findings at baseline colonoscopy, low-risk individuals carriers of rs2274403AA genotype in ABCC4 gene had a lower interval until recurrence (85 (29140) vs 122 (109-135), P=0.011) with 44% of metachronous tumors developing by 36 months (vs 23% for AG/GG). This study demonstrates for the first time the involvement of genetic variants in PGE2 transporters in colorectal adenoma recurrence. The incorporation of genetically-based approaches might allow an optimization of current risk models for the development of metachronous colorectal adenomas or even more advanced lesions possible laeding to a decrease in CRC burden and mortality.

Background & Aims Colonoscopy is the recommended screening procedure for first-degree relatives of patients with colorectal cancer (CRC), but few studies have compared its efficacy for CRC detection with that of other screening strategies. We conducted a controlled randomized trial to compare the efficacy of repeated fecal immunochemical tests (FITs) and colonoscopy in detecting advanced neoplasia (advanced adenoma or CRC) in family members of patients with CRC. Methods In a prospective study, 1918 first-degree relatives of patients with CRC were randomly assigned (1:1 ratio) to receive a single colonoscopy examination or 3 FITs (1/year for 3 years; OC-Sensor; cutoff ≥10 μg hemoglobin/g feces, corresponding to 50 ng hemoglobin/mL buffer). The strategies were considered to be equivalent if the 95% confidence interval of the difference for the detection of advanced neoplasia was ±3%. Follow-up analyses were performed to identify false-negative FIT results and interval CRCs. Results Of all eligible asymptomatic first-degree relatives, 782 were included in the colonoscopy group and 784 in the FIT group. In the intention-to-screen analysis, advanced neoplasia was detected in 33 (4.2%) and 44 (5.6%) first-degree relatives in the FIT and colonoscopy groups, respectively (odds ratio = 1.41; 95% confidence interval: 0.88–2.26; P = .14). In the per-protocol analysis, 28 first-degree relatives (3.9%) in the FIT group and 43 (5.8%) in the colonoscopy group had advanced neoplasia (odds ratio = 1.56; 95% confidence interval: 0.95–2.56; P = .08). FIT missed 16 of 41 advanced adenomas but no CRCs. The FIT strategy required endoscopic evaluation of 4-fold fewer individuals to detect 1 advanced neoplasia than the colonoscopy strategy. Conclusions Repeated FIT screening (1/year for 3 years) detected all CRCs and proved equivalent to colonoscopy in detecting advanced neoplasia in first-degree relatives of patients with CRC. This strategy should be considered for populations where compliance with FITs is higher than with colonoscopy. ClinicalTrials.gov number: NCT01075633 (COLONFAM Study).

Objetivo Analizar la influencia de polimorfismos de genes que codifican la sintesis de citocinas pro- y anti-inflamatorias, asi como de las ciclooxigenasas 1 (COX1) y 2 (COX2), en el pronostico del cancer gastrico (CG). Pacientes y metodos Se incluyeron prospectivamente 332 pacientes con CG distal y 65 pacientes con CG cardial desde Mayo de 2002 hasta Diciembre de 2003. El ADN obtenido a partir de sangre periferica fue tipado para el estudio de 24 polimorfismos localizados en genes de citocinas pro-inflamatorias (IL-1B, TNFA, LTA e IL-12p40) y anti-inflamatorias (IL-4, IL-1RN, IL-10 y TGFB1) asi como de COX1 (PTGS1) y COX2 (PTGS2) mediante PCR, RFLP y sondas Taqman. Se excluyeron 107 pacientes por: ausencia de estadio tumoral (n=56), exitus por causa no relacionada con la neoplasia (n=25) y ausencia de seguimiento (n=26). Finalmente se incluyeron 290 pacientes en el analisis. La mediana de seguimiento fue de 282 dias (rango: 5–2221). La supervivencia se analizo mediante los tests de Kaplan-Meier y log-rank. El pronostico de los polimorfismos se realizo mediante analisis de riesgos proporcionales de Cox, ajustando por edad, sexo, indice de comorbilidad de Charlson, tabaquismo, localizacion de la neoplasia y estadio tumoral. Resultados La edad media de los pacientes fue de 69,7±12,2 anos. 194 pacientes (67%) eran varones. En el momento de inclusion, 49 (17%), 27 (9%), 57 (20%) y 157 (54%) pacientes pertenecian a los estadios I–IV, respectivamente. Se realizo gastrectomia con intencion curativa en 123 (42%) pacientes. Durante el seguimiento fallecieron 196 (67%) pacientes: 160 (55%) por progresion de la neoplasia, y el resto por otras causas. La supervivencia media global a los 5 anos fue del 22%. La supervivencia media por estadios I–IV fue de 61%, 42%, 24% y 3%, respectivamente. Los individuos portadores del genotipo TGFB1-869CC presentaron un peor pronostico que los no portadores. Se identificaron como factores de mal pronostico la edad (HR=1,02, IC95%: 1,00–1,34, P=0,03), localizacion cardial de la neoplasia (HR=1,52, IC95%: 0,99–2,33, P=0,05), tabaquismo activo o previo (HR=1,59, IC95%: 1,10–2,29, P=0,01), estadio III (HR=3,35, IC95%: 1,67–6,70, P=0,001), estadio IV (HR=8,55, IC95%: 4,59–15,92, P Conclusion La combinacion de los genotipos PTGS1 644CC/TGFB1 869CC es un factor independiente de mal pronostico en pacientes con adenocarcinoma gastrico.

Relevance of GSTM1, GSTT1, and GSTP1 Gene Polymorphisms On Gastric Cancer Susceptibility Maria Asuncion Garcia-Gonzalez, Enrique Quintero, Rafael Benito, Mark Strunk, David Nicolas-Perez, Adolfo Parra-Blanco, Santos Santolaria, Federico Sopena, Elena Piazuelo, Pilar Jimenez, Maria Badia, Jesus Espinel, Rafael Campo, Marisa Manzano, Fernando Geijo, Maria Pellise, Ferran Gonzalez-Huix, Miguel Nieto, Jorge C. Espinos, LLucia Tito, Luis Bujanda, Manuel Zaballa, Maria Angeles Perez-Aisa, Isabel Maria Mendez-Sanchez, Angel Lanas