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Background and Aim: In Japan, screening colonoscopy for colorectal cancer is expected to reduce colorectal cancer mortality, although its complication rate has not been sufficiently examined. The aim of this study is to analyze severe complications due to colonoscopy., Methods: As a study population, we retrospectively used commercially anonymized health insurance claims data covering 5.71 million patients from January 2005 to August 2018. We extracted patients who received colonoscopy with lesions resection or without treatment. Main outcomes were rates of hemorrhage, perforation, fatal events, and their risk factors., Results: Among 341 852 colonoscopy without treatment in 260 128 patients (mean age: 49.6 ± 11.7 years), the rates of hemorrhage, perforation, and fatal events were 0.0059% (95% confidence interval [CI] 0.0031-0.0085), 0.0032% (95% CI 0.0011-0.0052), and 0.00029% (95% CI 0-0.0012), respectively. Regarding hemorrhage, compared with the rate for patients <50 years old (0.0050%), the rates for those 50-59, 60-69, and ≥70 years old were 0.0095% (P = 0.17), 0.0031% (P = 0.17), and 0%, respectively. Regarding perforation, compared with patients <50 years old (0.0056%), the rates for those 50-59, 60-69, and ≥70 years old were 0%, 0.0015% (P = 0.99), and 0.0102% (P = 0.99), respectively. A multivariate analysis for risk factors showed no significant findings for hemorrhage and perforation without treatment. Among 123 087 colonoscopy with lesions resection in 102 058 patients (mean age: 53.7 ± 9.3 years), the rates of hemorrhage, perforation, and fatal events were 0.136% (95% CI 0.1157-0.1572), 0.033% (95% CI 0.0228-0.0437), and 0.00081% (95% CI 0-0.0035), respectively., Conclusions: The analysis using health insurance claims data demonstrated the safety of colonoscopy., (© 2021 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Introduction: The number of colonoscopy (CS) for the elderly is increasing. There are only a few reports focusing on CS among the very elderly aged ≥ 90-y. We aimed to analyze the efficacy of CS and of colorectal cancer (CRC) for patients aged ≥ 90-y., Methods: We retrospectively analyzed consecutive patients aged ≥ 90-y receiving CS at eight institutions from October 2016 to September 2017. Bowel preparation, complications, and endoscopic diagnosis were analyzed. The non-elderly group aged between 50-y and 64-y and elderly group aged between 65-y and 79-y were compared to very-elderly group aged ≥ 90-y. Through propensity score matching of sex and CS indications (symptomatic or asymptomatic), the number of CRC and the treatment in each group were analyzed., Results: We analyzed 125 patients receiving 154 colonoscopies (0.9%) in the very-elderly group from among 16,968 cases. Among 92 cases who received bowel-cleansing solution, good preparations were achieved in 94.5%. The rate of CS-related complications was 1.3% (2/154). The rate of CRC in the very-elderly group was 27.2% (34/125), higher than the non-elderly group (7.2%, 9/125, p < 0.01) and elderly group (8.8%, 11/125, p < 0.01). Therapeutic interventions for CRC in the very-elderly group were performed in 73.5% (24/34) patients. The mean survival of 12 patients with CRC resection was 788 days., Conclusions: CS could be performed safely for the very elderly aged ≥ 90-y with careful considerations. CRC was confirmed to be more frequent in this group with over 70% of patients receiving appropriate therapeutic intervention.

Background and Aims: The use of endoscopic treatment for early colorectal cancer (ECC) is increasing. The European guidelines suggest performing piecemeal endoscopic resection (pmR) for benign lesions and en bloc resection for ECC, especially for patients with favorable lymph node involvement risk evaluations. However, en bloc resections for lesions larger than two centimeters require invasive endoscopic techniques. Our retrospective single-center study aimed to determine the clinical impact of performing pmR for ECC rather than traditional en bloc resection., Methods: A single-center study was performed between January 2012 and September 2017. All ECC patients were included. The main objective was to evaluate the number of patients who potentially underwent unnecessary surgery due to piecemeal resection. The secondary endpoints were as follows: disease-free survival (DFS), defined as the time from pmR to endoscopic failure (local recurrence not treatable by endoscopy), complication rate, number of patients who did not undergo surgery by default, and factors predictive of outcomes and complications., Results: One hundred and forty-six ECC endoscopically treated patients were included. In total, 85 patients were excluded (71 who underwent en bloc resection, 14 with pending follow-up). Data from 61 patients (33 women and 28 men) were analyzed. Two patients underwent potentially unnecessary surgery [3.28% (0.9%- 11.2%)]. The DFS rate was 87% (75%-93%) at 6 months and 85% [72%-92%] at 12 months. The median follow- up time was 16.5 months (12.4-20.9). Three patients (4.9%) had complications. One patient did not undergo surgery by default. A Paris classification of 0-2c (HR=9.3 (2.4-35.9), p<0.001) and Vienna classification of 5 [HR=16.3 (3.3-80.4), p<0.001] were factors associated with poor DFS., Conclusion: Performing pmR in place of en bloc resection for ECC had a limited impact on patients. If the pathology (especially deep margins) is analyzable, careful monitoring could be acceptable in ECC patients who undergo pmR.

Background: Endoscopic resection (polypectomy) or surgery, are the main approaches in management of malignant colon polyps. There are very few large population-based studies comparing outcomes between the two., Methods: Using the National Cancer Database, we identified patients ≥ 18 years with the first diagnosis of T1N0M0 malignant polyp from 2004 to 2015. Patients with a positive resection margin were excluded. Outcomes were compared between those who had surgery versus those who had polypectomy. Overall survival was compared using Kaplan-Meier curves. Multivariate Cox proportional hazards analysis was performed to generate hazard ratios, adjusted for patient, demographic, and tumor factors., Results: A total of 31,062 patients met the inclusion criteria, out of which 2593 (8.3%) underwent polypectomy alone and 28,469 (91.7%) had surgery. Overall survival was significantly better in the surgical group compared with the polypectomy group. One-year and 5-year survival for surgery were 95.8% and 86.1% respectively compared with 94.2% and 80.6% for polypectomy (p < .0001). Hazard ratio for surgery after adjusting for various clinical-, demographic-, and tumor-level factors was 0.53 (p < .0001)., Conclusion: Our study is the largest population-based analysis of patients with T1N0M0 malignant colon polyps. Overall survival was higher in patients who underwent surgery compared with polypectomy. This remained consistent even after adjusting for multiple patient and tumor factors between the two groups.

Background and Aim: Population-based studies on post-colonoscopy colorectal cancer (CRC) from Asia are sparse. We aimed to determine the characteristics and predictive factors and survival of post-colonoscopy CRC in Hong Kong., Methods: This is a territory-wide retrospective cohort study. Patients aged ≥ 40 years with colonoscopies performed between 2005 and 2013 without history of CRCs, inflammatory bowel disease, and prior colectomy were included. Post-colonoscopy colorectal cancer for an interval of 3 years (PCCRC-3y) was defined as CRC diagnosed between 6 and 36 months after index colonoscopy, whereas CRC diagnosed within 6 months of index colonoscopy was regarded as "detected CRC." We used multivariable logistic regression to derive adjusted odds ratio (aOR) of PCCRC-3y and Cox model for adjusted hazard ratio (aHR) of cancer-specific mortality after CRC diagnosis., Results: Of the 197 902 eligible patients, 10 005 (92.1%) were detected CRC and 854 (7.9%) PCCRC-3y. The median age at PCCRC-3y diagnosis was 75.9 years (interquartile range: 65.5-83.8)-a delay of 1.2 years (interquartile range: 0.8-1.9) from index colonoscopy-and 60.1% were male. Predictive factors for PCCRC-3y included older age (aOR: 1.07), male sex (aOR: 1.45), history of colonic polyps (aOR: 1.31), polypectomy/biopsy at index colonoscopy (aOR: 3.97), surgical endoscopists (aOR: 1.53), and a higher center annual endoscopy volume. Independent predictive factors for cancer-specific mortality after CRC diagnosis included PCCRC-3y (aHR: 1.32), proximal cancer location (aHR: 1.80), and certain patient factors., Conclusion: The PCCRC-3y rate was 7.9% in Hong Kong, with a high proportion (> 80%) of distal cancers and a higher cancer-specific mortality compared with detected CRC., (© 2019 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aims: The optimal treatment of patients with malignant colorectal polyps is unsettled. The surgical dilemma following polypectomy is selecting between watchful waiting (WW) and subsequent bowel resection (SBR), but the long-term survival outcomes have not been established yet. This nationwide study compared survival of patients after WW or SBR., Methods: Danish nationwide study with 100% follow-up of all patients with malignant colorectal polyps (the Danish Colorectal Cancer Group database) in a 10-year period from 2001 to 2011. All patients' charts and histological reports were individually reviewed. Survival rates were calculated with Cox proportional hazard model after propensity score matching., Results: A total of 692 patients were included (WW, 424 (61.3%), SBR, 268 (38.7%)) with a mean follow-up of 7.5 years (3-188 months). Following propensity score matching, there was no significant difference in overall or disease-free survival (p = 0.344 and p = 0.184) or rate of local recurrence (WW, 7.2%, SBR, 2%, p = 0.052) or distant metastases (WW, 3.3%, SBR, 4.6%, p = 0.77). In the SBR group, there was no residual tumor or lymph node metastases in the resected specimen in 82.5% of the patients., Conclusion: Subsequent bowel resection may not be superior to endoscopic polypectomy and watchful waiting with regard to overall and disease-free survival in patients with malignant colorectal polyps.

Background: The full spectrum of serious non-gastrointestinal post-colonoscopy complications has not been well characterized. We analyzed rates of and factors associated with adverse post-colonoscopy gastrointestinal (GI) and non-gastrointestinal events (cardiovascular, pulmonary, or infectious) attributable to screening or surveillance colonoscopy (S-colo) and non-screening or non-surveillance colonoscopy (NS-colo)., Methods: We performed a population-based study of colonoscopy complications using databases from California hospital-owned and nonhospital-owned ambulatory facilities, emergency departments, and hospitals from January 1, 2005 through December 31, 2011. We identified patients who underwent S-colo (1.58 million), NS-colo (1.22 million), or low-risk comparator procedures (joint injection, aspiration, lithotripsy; arthroscopy, carpal tunnel; or cataract; 2.02 million) in California's Ambulatory Services Databases. We identified patients who developed adverse events within 30 days, and factors associated with these events, through patient-level linkage to California's Emergency Department and Inpatient Databases., Results: After S-colo, the numbers of lower GI bleeding, perforation, myocardial infarction, and ischemic stroke per 10,000-persons were 5.3 (95% confidence interval [CI], 4.8-5.9), 2.9 (95% CI, 2.5-3.3), 2.5 (95% CI, 2.1-2.9), and 4.7 (95% CI, 4.1-5.2) without biopsy or intervention; with biopsy or intervention, numbers per 10,000-persons were 36.4 (95% CI, 35.1-37.6), 6.3 (95% CI, 5.8-6.8), 4.2 (95% CI, 3.8-4.7), and 9.1 (95% CI, 8.5-9.7). Rates of dysrhythmia were higher. After NS-colo, event rates were substantially higher. Most serious complications led to hospitalization, and most GI complications occurred within 14 days of colonoscopy. Ranges of adjusted odds ratios for serious GI complications, myocardial infarction, ischemic stroke, and serious pulmonary events after S-colo vs comparator procedures were 2.18 (95% CI, 2.02-2.36) to 5.13 (95% CI, 4.81-5.47), 0.67 (95% CI, 0.56-0.81) to 0.99 (95% CI, 0.83-1.19), 0.66 (95% CI, 0.59-0.75) to 1.13 (95% CI, 0.99-1.29), and 0.64 (95% CI, 0.61-0.68) to 1.05 (95% CI, 0.98-1.11). Biopsy or intervention, comorbidity, black race, low income, public insurance, and NS-colo were associated with post-colonoscopy adverse events., Conclusions: In a population-based study in California, we found that following S-colo, rates of serious GI adverse events were low but clinically relevant, and that rates of myocardial infarction, stroke, and serious pulmonary events were no higher than after low-risk comparator procedures. Rates of myocardial infarction are similar to, but rates of stroke are higher than, those reported for the general population., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Improvements in colorectal cancer (CRC) mortality reflect the distribution of effective preventions. Social inequalities often generate unequal diffusion of medical interventions, resulting in disparate outcomes while preventions are being disseminated throughout the population. This study used a novel method to examine whether Race (Black versus White) and SES influenced when rates of CRC mortality started to decline, and how rapidly they did so., Method: Mortality counts from 1968-2010 were derived from death certificates of U.S. residents aged 25 + years. Individuals' race, age, county of residence, and sex were collected from death certificates. County-level SES was measured using the decennial U.S. census. Layered joinpoint regression was used to model CRC mortality trends over time. Acceleration in rates of historical decline were used to indicate preventability within counties., Results: Black race was associated with a 4.1-year delay in colonoscopy-attributable declines in CRC mortality and each standard deviation unit change in SES with a 5.7-year delay in such mortality. Following the onset of a decline, colonoscopy-attributable mortality change was slower by 0.5% among Blacks, and 2.0%/standard deviation in SES. Modifying the rapidity of colonoscopy uptake could have averted 12-14,000 and 83-86,000 deaths among Blacks and residents of lower SES counties, respectively., Conclusions: Successful interventions do not uniformly benefit the U.S., Population: This study highlighted the notable impact that substantial delays in the provision of interventions, and in the relative rapidity of dissemination, and estimated the extent to which there was a preventable loss of life concentrated amongst the most disadvantaged. A more egalitarian delivery of life-saving interventions could drastically reduce mortality by improving effectiveness of interventions while also addressing inequalities in health., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objectives: Psychological biases can distort treatment decision-making. The availability heuristic is one such bias, wherein events that are recent, vivid or easily imagined are readily 'available' to memory and are therefore judged more likely to occur than expected based on epidemiological data. We assessed if the occurrence of a serious colonoscopy complication for a primary care physician's patient influenced colonoscopy rates for the physician's other patients., Design: Longitudinal study with time-varying exposure variables., Setting/participants: Individuals living in 51 hospital referral regions across the USA identified based on enrolment in fee-for-service Medicare during 2005-2010. We assigned patients to a primary care physician based on office visits during the prior 2 years., Exposures: For each physician in each month, we calculated the proportion of patients assigned to them who had a colonoscopy. We identified two serious complications of which the primary care provider would very likely be aware: gastrointestinal bleed or perforation leading to hospitalisation or death within 14 days of colonoscopy., Main Outcome Measures: We employed Poisson regression models including physician fixed effects to assess the change in number of colonoscopies in the four quarters following an adverse colonoscopy event., Results: We identified 5 360 191 patients assigned to 30 704 physicians. 4864 physicians (16%) had at least one patient with an adverse event. The estimated change in the quarterly number of colonoscopies among physicians' patients was significantly lower in quarter 2 following an adverse colonoscopy event (change=-2.1% (95% CI -3.4 to -0.8%)), before returning to the rate expected in the absence of an adverse event., Conclusions: Having a patient experience a serious adverse colonoscopy event was associated with a small and temporary decline in colonoscopy rates among a physician's other patients. This finding provides empirical evidence for the influence of notable adverse events on care, possibly due to the availability heuristic., Competing Interests: Competing interests: NLK previously served as a medical editor for the Informed Medical Decisions Foundation, now part of Healthwise, a non-profit organisation that seeks to improve healthcare decisions., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Transrectal access still has some unsolved issues such as spatial orientation, infection, access and site closure. This study presents a simple technique to perform transcolonic access with survival in a swine model series. A new technique for NOTES perirectal access to perform retroperitoneoscopy, peritoneoscopy, liver and lymphnode biopsies was performed in 6 pigs, using Totally NOTES technique. The specimens were extracted transanally. The flexible endoscope was inserted through a posterior transmural incision and the retrorectal space. Cultures of bacteria were documented for the retroperitoneal space and intra abdominal cavity after 14 days. Rectal site was closed using non-absorbable sutures. There was no bowel cleansing, nor preoperative fasting. The procedures were performed in 6 pigs through transcolonic natural orifice access using available endoscopic flexible instruments. All animals survived 14 days without complications, and cultures were negative. Histopathologic examination of the rectal closure site showed adequate healing of suture line and no micro abscesses. The results of feasibility and safety of experimental Transcolonic NOTES potentially brings new frontiers and future wider applications for minimally invasive surgery. The treatment of colorectal, abdominal and retroperitoneal diseases through a flexible Perirectal NOTES Access (PNA) is a promising new approach.

Aim: To understand the influence of frailty on postoperative outcomes for laparoscopic and open colectomy., Methods: Data were obtained from the National Surgical Quality Improvement Program (2005-2012) for patients undergoing colon resection [open colectomy (OC) and laparoscopic colectomy (LC)]. Patients were classified as non-frail (0 points), low frailty (1 point), moderate frailty (2 points), and severe frailty (≥ 3) using the Modified Frailty Index. 30-d mortality and complications were used as the primary end point and analyzed for the overall population. Complications were grouped into major and minor. Subset analysis was performed for patients undergoing colectomy (total colectomy, partial colectomy and sigmoid colectomy) and separately for patients undergoing rectal surgery (abdominoperineal resection, low anterior resection, and proctocolectomy). We analyzed the data using SAS Platform JMP Pro version 10.0.0 (SAS Institute Inc., Cary, NC, United States)., Results: A total of 94811 patients were identified; the majority underwent OC (58.7%), were white (76.9%), and non-frail (44.8%). The median age was 61.3 years. Prolonged length of stay (LOS) occurred in 4.7%, and 30-d mortality was 2.28%. Patients undergoing OC were older (61.89 ± 15.31 vs 60.55 ± 14.93) and had a higher ASA score (48.3% ASA3 vs 57.7% ASA2 in the LC group) ( P < 0.0001). Most patients were non-frail (42.5% OC vs 48% LC, P < 0.0001). Complications, prolonged LOS, and mortality were significantly more common in patients undergoing OC ( P < 0.0001). OC had a higher risk of death and complications compared to LC for all frailty scores (non-frail: OR = 4.7, and OR = 4.67; mildly frail: OR = 2.51, and OR = 2.47; moderately frail: OR = 2.94, and OR = 2.02, severely frail: OR = 2.37, and OR = 2.34, P < 0.05) and an increase in absolute mortality with increasing frailty (non-frail 0.68% OC, mildly frail 1.39%, moderately frail 3.44%, and severely frail 5.83%, P < 0.0001)., Conclusion: LC is associated with improved outcomes. Although the odds of mortality are higher in non-frail, there is a progressive increase in mortality with increasing frailty., Competing Interests: Conflict-of-interest statement: We have no financial relationships to disclose.

Though endoscopic treatment is an option for T1 colorectal cancer (CRC), the optimal indications and long-term outcomes of this strategy need to be validated. Therefore, the aim of this study is to investigate long-term outcomes of endoscopy versus surgery and optimal indications for endoscopic treatment of T1 CRC.This retrospective study included 428 T1 CRC patients treated with initial endoscopy (n = 224) or surgery (n = 204) at Severance Hospital between 2005 and 2012. Patients were subdivided into 4 groups according to conventional indications (CIs) for endoscopic treatment: negative lateral/vertical margins; submucosal invasion depth within 1000 μm; no lymphovascular invasion (LVI); well or moderately differentiated. For prognosis evaluation, short-term outcomes (resection margin and complications) and long-term outcomes (recurrence and cancer-specific mortality) were evaluated.Endoscopic treatment achieved en bloc resection in 86.6% of 224 patients. Recurrence and mortality did not differ between the endoscopy and surgery groups with or without CIs. For patients with CIs, although 80 patients were treated endoscopically with 1 (1.3%) recurrence and 0 mortality, 75 patients were treated surgically with 2 (2.7%) recurrence and 1 (1.3%) mortality. Multivariate analysis revealed that LVI positivity and poorly differentiated histology were independently associated with lymph node metastasis (LNM; P < 0.001 and P = 0.001, respectively).To determine whether the depth of submucosal invasion among criteria of CIs could be extended for endoscopic treatment, LNM was analyzed by extending the depth of submucosal invasion. There was no LNM in 155 patients within conventional indication. When the depth of submucosal invasion was extended up to 1500 μm, LNM was occurred (1/197 patient [0.5%]). In addition, when the depth of submucosal invasion was extended up to 2000 μm, LNM was increased (4/271 patient [1.5%]).Endoscopic treatment is safe, effective, and is associated with favorable long-term outcomes compared to surgery for initial treatment of T1 CRC patients with CIs. However, the risk of LNM makes it unsafe to extend the CIs for endoscopic therapy in these patients.

Objectives: Many studies around the world addressed the post-colonoscopy complications, but their pooled prevalence and time trends are unknown. We performed a systematic review and meta-analysis of population-based studies to examine the pooled prevalence of post-colonoscopy complications ("perforation", "bleeding", and "mortality"), stratified by colonoscopy indication. Temporal variability in the complication rate was assessed., Methods: We queried Pubmed, Embase, and the Cochrane library for population-based studies examining post-colonoscopy complications (within 30 days), performed from 2001 to 2015 and published by 1 December 2015. We determined pooled prevalence of perforations, post-colonoscopy bleeding, post-polypectomy bleeding, and mortality., Results: We retrieved 1,074 studies, of which 21 met the inclusion criteria. Overall, pooled prevalences for perforation, post-colonoscopy bleeding, and mortality were 0.5/1,000 (95% confidence interval (CI) 0.4-0.7), 2.6/1,000 (95% CI 1.7-3.7), and 2.9/100,000 (95% CI 1.1-5.5) colonoscopies. Colonoscopy with polypectomy was associated with a perforation rate of 0.8/1,000 (95% CI 0.6-1.0) and a post-polypectomy bleeding rate of 9.8/1,000 (95% CI 7.7-12.1). Complication rate was lower for screening/surveillance than for diagnostic examinations. Time-trend analysis showed that post-colonoscopy bleeding declined from 6.4 to 1.0/1,000 colonoscopies, whereas the perforation and mortality rates remained stable from 2001 to 2015. Overall, considerable heterogeneity was observed in most of the analyses., Conclusions: Worldwide, the post-colonoscopy complication rate remained stable or even declined over the past 15 years. The findings of this meta-analysis encourage continued efforts to achieve and maintain safety targets in colonoscopy practice.

Objective: The potential for cancers to not be detected on colonoscopy is increasingly recognised, but little is known about patient outcomes. The objective of this study was to assess the outcomes of patients diagnosed with postcolonoscopy colorectal cancers (PCCRCs)., Design: We conducted a population-based retrospective cohort study, including all patients diagnosed with colorectal cancer (CRC) in Ontario, Canada from 2003 to 2009. Patients were categorised into three groups: DETECTED (diagnosed within 6 months of first colonoscopy), PCCRC (diagnosed 6-36 months after first colonoscopy) or NOSCOPE (no colonoscopy within 36 months of diagnosis). Univariate and multivariable analyses were conducted to study overall survival, surgical treatment, emergency presentation and surgical complications., Results: Overall, 45 104 patients were included, with 2804 being classified as having a PCCRC. Compared with the DETECTED group, PCCRC was associated with a significantly higher likelihood of stage IV disease (17.2% vs 12.9%), worse overall survival (5 year OS: 60.8% vs 68.3%, p<0.0001; adjusted HR: 1.25, 95% CI 1.17 to 1.32, p<0.0001), a higher likelihood of emergency presentation (OR: 2.86, 95% CI 2.56 to 3.13, p<0.001) and lower likelihood of surgical resection (OR: 0.61, 95% CI 0.55 to 0.67, p<0.001). However, patients with PCCRC had significantly better outcomes than those in the NOSCOPE group (stage IV: 37.1%, 5 year OS: 38.9%), Conclusions: Compared with CRC detected by colonoscopy, PCCRCs are associated with a higher risk of emergent presentation, a lower likelihood of surgical resection and most notably, significantly worse oncological outcomes. However, they have better outcomes than patients with no recent colonoscopy., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Aim: To evaluate the type of recurrence after endoscopic resection in colorectal cancer patients and whether rescue was possible by salvage operation., Methods: Among 4972 patients who underwent surgical resection at our institution for primary or recurrent colorectal cancers from January 2005 to February 2015, we experienced eight recurrent colorectal cancers after endoscopic resection when additional surgical resection was recommended., Results: The recurrence patterns were: intramural local recurrence (five cases), regional lymph node recurrence (three cases), and associated with simultaneous distant metastasis (three cases). Among five cases with lymphatic invasion observed histologically in endoscopic resected specimens, four cases recurred with lymph node metastasis or distant metastasis. All cases were treated laparoscopically and curative surgery was achieved in six cases. Among four cases located in the rectum, three cases achieved preservation of the anus. Postoperative complications occurred in two cases (enteritis)., Conclusion: For high-risk submucosal invasive colorectal cancers after endoscopic resection, additional surgical resection with lymphadenectomy is recommended, particularly in cases with lymphovascular invasion.

Background: In October 2002, screening colonoscopy from age 55 onward was introduced as part of the German national statutory cancer screening program. Screening colonoscopy is intended to lower both the mortality and the incidence of bowel cancer by enabling the detection and removal of precursor lesions., Methods: The authors studied trends in bowel cancer incidence and mortality in Germany from 2003 to 2012 on the basis of data from the epidemiological cancer registries and from cause-of-death statistics., Results: Over the period of investigation, the age-standardized incidence of bowel cancer (with the European population as a standard) fell from 66.1 to 57.0 cases per 100 000 persons per year (-13.8%) in men and from 42.6 to 36.5 per 100 000 persons per year (-14.3%) in women. In parallel with these changes, the age-standardized mortality from bowel cancer fell by 20.8% in men and by 26.5% in women. In the age groups 55-64, 65-74, and 75-84 years, the cumulative risk of receiving a diagnosis of bowel cancer fell by 17-26%; in persons under age 55, this risk fell by only 3% in men, but increased by 14% in women. Long-term data from the cancer registry in the German federal state of Saarland revealed that the incidence of bowel cancer, but not its mortality, had risen over the decades preceding the study; it was only during the period of investigation that the trend reversed itself., Conclusion: Within 10 years of the introduction of screening colonoscopy in Germany, the incidence of bowel cancer in persons over age 55 fell by 17-26%, after having risen steadily over the preceding decades.

Aim: To evaluate the long-term effectiveness of colonic stents in colorectal tumors causing large bowel obstruction., Methods: We retrospectively analyzed data from 49 patients with colorectal cancer who had undergone colorectal stent placement between January 2008 and January 2013. Patients' symptoms, characteristics and clinicopathological data were obtained by reviewing medical records. The obstruction was diagnosed clinically and radiologically. Histopathological diagnosis was achieved endoscopically. Technical success rate (TSR) was defined as the ratio of patients with correctly placed SEMS upon stent deployment across the entire stricture length to total number of patients. Clinical success rate (CSR) was defined as the ratio of patients with technical success and successful maintenance of stent function before elective surgery (regardless of number of SEMS deployed) to total number of patients. The surgical success rate (SSR) of colorectal stent as a bridge to surgery was defined as the ratio of patients with successful surgical procedures. Unsuccessful surgical outcomes were defined as being due to insufficient colonic decompression. The technical, clinical, surgical success rates and complications after stenting were assessed., Results: The median age of patients was 64 (36 to 89). 44.9% of patients were male and 55.1% were female. Eighteen patients had the obstruction located in the rectum, 15 patients in the rectosigmoid region, 10 patients in the sigmoid region, and 6 patients had a tumor causing obstruction in the proximal colon. Each patient was categorized pathologically as stage 2 (32.7%, 16 patients) or stage 3 (42.9%, 21 patients) and 12 patients (24.4%) had metastatic disease. None of the patients received chemotherapy before stenting. Stenting was undertaken in 37 patients as a bridge to surgery, and in 12 patients stents were used for palliation. Median time to surgery after stenting was 30 ± 91.9 d. All surgery was completed in one single operation and thus no colostomy with stoma was needed. The median overall survival rate of patients with stage 2-3 colorectal cancer was 53.1 mo and stage 4 was 37.1 mo (P = 0.04). Metastatic colorectal patients who were treated palliatively with stents had backbone chemotherapy with oxaliplatin and/or irinotecan-based regimens plus antiangiogenic therapies, especially bevacizumab. Resolution of the obstruction and clinical improvement was achieved in all patients. The technical, clinical and surgical success rates were 95.9%, 100% and 94.6%, respectively., Conclusion: The efficacy and safety of colonic stents was demonstrated both as a bridge to surgery and for palliative decompression. In addition, results emphasize the importance of the skills of the endoscopist in colonic stenting.

Single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) have rapidly gained pace worldwide, potentially replacing conventional laparoscopic surgery (CLS) as the preferred colorectal surgery technique. Currently available data mainly consist of retrospective series analyzed in four meta-analyses. Despite conflicting results and lack of an objective comparison, SILS appears to offer cosmetic advantages over CLS. However, due to conflicting results and marked heterogeneity, present data fail to show significant differences in terms of operative time, postoperative morbidity profiles, port-site complications rates, oncological appropriateness, duration of hospitalization or cost when comparing SILS with conventional laparoscopy for colorectal procedures. The application of "pure" NOTES in humans remains limited to case reports because of unresolved issues concerning the ideal access site, distant organ reach, spatial orientation and viscera closure. Alternatively, minilaparoscopy-assisted natural orifice surgery techniques are being developed. The transanal "down-to-up" total mesorectum excision has been derived for transanal endoscopic microsurgery (TEM) and represents the most encouraging NOTES-derived technique. Preliminary experiences demonstrate good oncological and functional short-term outcomes. Large-scale randomized controlled trials are now mandatory to confirm the long-term SILS results and validate transanal TEM for the application of NOTES in humans.

Aim: To assess the outcome of patients treated conservatively vs surgically during their first admission for sigmoid volvulus., Methods: We conducted a retrospective study of 61 patients admitted to Aarhus University Hospital in Denmark between 1996 and 2011 for their first incidence of sigmoid volvulus. The condition was diagnosed by radiography, sigmoidoscopy or surgery. Patients treated with surgery underwent either a sigmoid resection or a percutaneous endoscopic colostomy (PEC). Conservatively treated patients were managed without surgery. Data was recorded into a Microsoft Access database and calculations were performed with Microsoft Excel. Kaplan-Meier plotting and Mantel-Cox (log-rank) testing were performed using GraphPad Prism software. Mortality was defined as death within 30 d after intervention or surgery., Results: Among the total 61 patients, 4 underwent emergency surgery, 55 underwent endoscopy, 1 experienced resolution of the volvulus after contrast enema, and 1 died without treatment because of large bowel perforation. Following emergency treatment, 28 patients underwent sigmoid resection (semi-elective n = 18; elective n = 10). Two patients who were unfit for surgery underwent PEC and both died, 1 after 36 d and the other after 9 mo, respectively. The remaining 26 patients were managed conservatively without sigmoid resection. Patients treated conservatively on their first admission had a poorer survival rate than patients treated surgically on their first admission (95%CI: 3.67-14.37, P = 0.036). Sixty-three percent of the 26 conservatively treated patients had not experienced a recurrence 3 mo after treatment, but that number dropped to 24% 2 years after treatment. Eight of the 14 patients with recurrence after conservative treatment had surgery with no 30-d mortality., Conclusion: Surgically-treated sigmoid volvulus patients had a higher long-term survival rate than conservatively managed patients, indicating a benefit of surgical resection or PEC insertion if feasible.

Background: EMR of advanced mucosal neoplasia (AMN) (ie, sessile or laterally spreading lesions of ≥20 mm) of the colon has become an increasingly popular alternative to surgical resection. However, data regarding safety and mortality of EMR in comparison to surgery are limited., Objective: To compare actual endoscopic with predicted surgical mortality., Design: Prospective, observational, multicenter cohort study., Setting: Academic, high-volume, tertiary-care referral center., Patients: Consecutive patients referred for EMR., Intervention Emr Main Outcome Measurements: To predict hypothetical surgical mortality, the Association of Coloproctology of Great Britain and Ireland score, composed of physiological and surgical components, was calculated for each patient. Predicted surgical mortality was then compared with actual outcomes of EMR. The results were validated by an unselected subcohort by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity., Results: Among 1050 patients with AMN treated by EMR, including patients with a predicted mortality rate of greater than 5% (13.8% of cohort), no deaths occurred within 30 days after the procedure. The predicted surgical mortality rate was 3.3% with the Association of Coloproctology of Great Britain and Ireland score (P < .0001). This suggests a significant advantage of EMR over surgery. The results were validated by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity in 390 patients predicting a surgical mortality rate of 3.2% (P = .0003)., Limitations: Nonrandomized study., Conclusion: In this large multicenter study of EMR for colonic AMN, the predicted surgical mortality rate was significantly higher than the actual endoscopic mortality rate. Given that endoscopic therapy is less morbid and less expensive than surgery and can be performed as an outpatient treatment, it should be considered as the first line of treatment for most patients with these lesions., (Copyright © 2014 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Objectives: To review, summarise, and compare the evidence for effectiveness of screening sigmoidoscopy and screening colonoscopy in the prevention of colorectal cancer occurrence and deaths., Design: Systematic review and meta-analysis of randomised controlled trials and observational studies., Data Sources: PubMed, Embase, and Web of Science. Two investigators independently extracted characteristics and results of identified studies and performed standardised quality ratings., Eligibility Criteria: Randomised controlled trials and observational studies in English on the impact of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality in the general population at average risk., Results: For screening sigmoidoscopy, four randomised controlled trials and 10 observational studies were identified that consistently found a major reduction in distal but not proximal colorectal cancer incidence and mortality. Summary estimates of reduction in distal colorectal cancer incidence and mortality were 31% (95% confidence intervals 26% to 37%) and 46% (33% to 57%) in intention to screen analysis, 42% (29% to 53%) and 61% (27% to 79%) in per protocol analysis of randomised controlled trials, and 64% (50% to 74%) and 66% (38% to 81%) in observational studies. For screening colonoscopy, evidence was restricted to six observational studies, the results of which suggest tentatively an even stronger reduction in distal colorectal cancer incidence and mortality, along with a significant reduction in mortality from cancer of the proximal colon. Indirect comparisons of results of observational studies on screening sigmoidoscopy and colonoscopy suggest a 40% to 60% lower risk of incident colorectal cancer and death from colorectal cancer after screening colonoscopy even though this incremental risk reduction was statistically significant for deaths from cancer of the proximal colon only., Conclusions: Compelling and consistent evidence from randomised controlled trials and observational studies suggests that screening sigmoidoscopy and screening colonoscopy prevent most deaths from distal colorectal cancer. Observational studies suggest that colonoscopy compared with flexible sigmoidoscopy decreases mortality from cancer of the proximal colon. This added value should be examined in further research and weighed against the higher costs, discomfort, complication rates, capacities needed, and possible differences in compliance., (© Brenner et al 2014.)

Background: Colorectal cancer is the third most frequent cancer in the world. As the sojourn time for this cancer is several years and a good prognosis is associated with early stage diagnosis, screening has been implemented in a number of countries. Both screening with faecal occult blood test and flexible sigmoidoscopy have been shown to reduce mortality from colorectal cancer in randomised controlled trials. The comparative effectiveness of these tests on colorectal cancer mortality has, however, never been evaluated, and controversies exist over which test to choose., Objectives: To compare the effectiveness of screening for colorectal cancer with flexible sigmoidoscopy to faecal occult blood testing., Search Methods: We searched MEDLINE and EMBASE (November 16, 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 11) and reference lists for eligible studies., Selection Criteria: Randomised controlled trials comparing screening with flexible sigmoidoscopy or faecal occult blood testing to each other or to no screening. Only studies reporting mortality from colorectal cancer were included. Faecal occult blood testing had to be repeated (annually or biennially)., Data Collection and Analysis: Data retrieval and assessment of risk of bias were performed independently by two review authors. Standard meta-analyses using a random-effects model were conducted for flexible sigmoidoscopy and faecal occult blood testing (FOBT) separately and we calculated relative risks with 95% confidence intervals (CI). We used a Bayesian approach (a contrast-based network meta-analysis method) for indirect analyses and presented the results as posterior median relative risk with 95% credibility intervals. We assessed the quality of evidence using GRADE., Main Results: We identified nine studies comprising 338,467 individuals randomised to screening and 405,919 individuals to the control groups. Five studies compared flexible sigmoidoscopy to no screening and four studies compared repetitive guaiac-based FOBT (annually and biennially) to no screening. We did not consider that study risk of bias reduced our confidence in our results. We did not identify any studies comparing the two screening methods directly. When compared with no screening, colorectal cancer mortality was lower with flexible sigmoidoscopy (relative risk 0.72; 95% CI 0.65 to 0.79, high quality evidence) and FOBT (relative risk 0.86; 95% CI 0.80 to 0.92, high quality evidence). In the analyses based on indirect comparison of the two screening methods, the relative risk of dying from colorectal cancer was 0.85 (95% credibility interval 0.72 to 1.01, low quality evidence) for flexible sigmoidoscopy screening compared to FOBT. No complications occurred after the FOBT test itself, but 0.03% of participants suffered a major complication after follow-up. Among more than 60,000 flexible sigmoidoscopy screening procedures and almost 6000 work-up colonoscopies, a major complication was recorded in 0.08% of participants. Adverse event data should be interpreted with caution as the reporting of adverse effects was incomplete., Authors' Conclusions: There is high quality evidence that both flexible sigmoidoscopy and faecal occult blood testing reduce colorectal cancer mortality when applied as screening tools. There is low quality indirect evidence that screening with either approach reduces colorectal cancer deaths more than the other. Major complications associated with screening require validation from studies with more complete reporting of harms

There is substantial indirect evidence for the effectiveness of colonoscopy in reducing colorectal cancer incidence and mortality. However, several recent studies have raised questions on the magnitude of effect for right-sided colorectal cancers. Well-documented variation in outcomes when colonoscopy is performed by different groups of endoscopists suggests that the recent emphasis on the quality of the procedures should lead to improved outcomes after colonoscopy including reduction in incidence and mortality due to right-sided colorectal cancers., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Aim: To investigate an appropriate strategy for the treatment of patients with acute sigmoid volvulus in the emergency setting., Methods: A retrospective review of 28 patients with acute sigmoid volvulus treated in the Department of Colorectal Surgery, Changhai Hospital, Shanghai from January 2001 to July 2012 was performed. Following the diagnosis of acute sigmoid volvulus, an initial colonoscopic approach was adopted if there was no evidence of diffuse peritonitis., Results: Of the 28 patients with acute sigmoid volvulus, 19 (67.9%) were male and 9 (32.1%) were female. Their mean age was 63.1 ± 22.9 years (range, 21-93 years). Six (21.4%) patients had a history of abdominal surgery, and 17 (60.7%) patients had a history of constipation. Abdominal radiography or computed tomography was performed in all patients. Colonoscopic detorsion was performed in all 28 patients with a success rate of 92.8% (26/28). Emergency surgery was required in the other two patients. Of the 26 successfully treated patients, seven (26.9%) had recurrent volvulus., Conclusion: Colonoscopy is the primary emergency treatment of choice in uncomplicated acute sigmoid volvulus. Emergency surgery is only for patients in whom nonoperative treatment is unsuccessful, or in those with peritonitis.

Background: The primary goal of this hospital-based retrospective multicenter case series study was to determine the incidence of large bowel full-thickness injury associated with colonoscopy in Lithuania. We assessed characteristics of patients who were treated as a result of this complication; management and outcomes were the secondary goals of this study., Methods: The medical records of patients with iatrogenic large bowel perforations resulting from colonoscopy within the period January 1, 2007, to December 31, 2011, were retrospectively reviewed. Representatives of 14 Lithuanian public and private hospitals participated in the survey., Results: A total of 56,882 colonoscopies were performed. Forty patients (23 female and 17 male patients) were reported to have iatrogenic full-thickness large bowel injury. Diagnostic and therapeutic colonoscopies resulted in perforation for 28 of 49,795 patients and 12 of 7,087 patients, respectively. A mean age of 70 years and a female preponderance for this complication was revealed. Sigmoid colon and rectosigmoid junction was perforated in 28 patients. All patients underwent surgical management, either primary repair (70.0 %) or bowel resection (30.0 %). Postoperative complications were diagnosed in 15 patients. Immediate treatment resulted in fewer intestinal resections and shorter hospital stays (p < 0.05). Smoking [odds ratio (OR) 14.4, 95 % confidence interval (CI) 1.16-179.8] and a large size perforation site (15 ± 10 vs. 8 ± 5 mm; OR 1.19, 95 % CI 1.03-1.38) were risk factors for developing a postoperative complication after curative surgery. Six patients died. All deaths were related to diagnostic colonoscopy., Conclusions: Total incidence of large bowel full-thickness injury in Lithuanian hospitals is 0.07 %. Incidence of this complication after diagnostic and therapeutic colonoscopies is 0.056 and 0.169 %, respectively. The most common site of perforation is sigmoid colon and rectosigmoid junction, at 70 %. Risk rises when colonoscopy is performed in low-volume practice centers. Urgent surgical management resulted in overall mortality rate of 15.0 % and morbidity of 37.5 %.

Background: The efficacy and safety of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery or definitive palliation versus emergency operation to treat colorectal obstruction is debated. This study aimed to evaluate the outcomes of patients with colorectal obstruction treated using different strategies., Methods: Subjects admitted to the authors' department with colorectal obstruction (n = 134) were studied prospectively. They underwent endoscopic stenting as a bridge to elective surgery (SEMS group: n = 49) or for definitive palliation (n = 34). A total of 51 patients underwent immediate surgery without stenting (NO-SEMS). Treatment was decided by the senior on-call surgeon., Results: Placement of SEMS was technically successful in 95.3 % and clinically successful in 98.7 % of cases. The short-term complications in the SEMS group were perforation (n = 1, 1.2 %), migration (n = 4, 4.9 %), occlusion (n = 4, 4.9 %), colon bleeding (n = 3, 3.7 %), and abdominal pain (n = 6, 7.4 %). The postoperative complication rate was 32.7 % in the SEMS group versus 60.8 % in the NO-SEMS group (P = 0.005), with a significant reduction in wound infections (26.5 vs 54.9 %; P = 0.004), abdominal abscess (14.3 vs 39.2 %; P = 0.006), respiratory morbidity (10.2 vs 37.3 %; P = 0.002), and intensive care treatment (10.2 vs 33.3 %; P = 0.007). The median postoperative hospital stay was 10 versus 15 days (P = 0.001). The in-hospital mortality rate in both groups was 2 %. Long-term follow-up evaluation showed less incisional hernia (6.3 vs 22.0 %; P = 0.04) and definitive stoma formation (6.3 vs 26.0 %; P = 0.01) in the SEMS group than in the NO-SEMS group, respectively. Kaplan-Meier survival curves showed a benefit for the SEMS group (log-rank test, 0.004). The long-term SEMS-related complication rate for the palliative patients was 43.8 %. The hospital readmission rate for SEMS complications was 34.4 %. Overall clinical success was 81.2 %., Conclusions: In case of colorectal obstruction, endoscopic colon stenting as a bridge to elective operation should be considered as the treatment of choice for resectable patients given the significant advantages for short- and long-term outcomes. Palliative stenting is effective but associated with a high rate of long-term complications.

Background: Surgical treatment of colorectal cancer (CRC) should be aimed primarily at achieving a combination of surgical-oncologic radicalness and the highest possible quality of life. In recent years, surgical therapy for T1 CRC has tended toward less radical interventions. The question regarding changes in survival and recurrence rates still is unanswered., Methods: A retrospective medical chart review of patients surgically treated in our department for T1 CRC from January 1990 to December 2010 (n = 223) was performed. Charts were reviewed for tumor-specific parameters, local recurrence, distant metastasis, and patient survival. The different treatment options used were strictly separated for a more detailed workup., Results: Radical resection (RR) was performed for 57.1 %, local resection (LR) for 14.8 %, and an endoscopic approach (EA) for 28.1 % of the study population. After receipt of the histology report, 35.7 % of the patients initially resected nonradically underwent reoperation, mostly using RR. Seven patients experienced a local recurrence over time (3.6 %): one after initial RR, three after LR, and three after EA. Systemic recurrence occurred for nine patients (4.6 %) over time, six of whom had undergone initial RR. High-risk criteria were shown for 20 T1 CRCs. For 60 % (12/20) of the patients, initial RR was performed. Radical reoperation was performed for 75 % of the nonradically treated high-risk tumors. One high-risk patient without reoperation experienced metastatic disease over time. The 5-year overall survival rate was 87.2 %, itemized for the defined subgroups as follows: 83.9 % for RR, 82.8 % for LR, and 58.2 % for EA., Conclusion: Patients with T1 CRC had a distinctly higher incidence of local recurrence after EA or LR. Explicit workup in terms of risk classification is crucial to reducing the risk of local and systemic recurrence. A nonradical approach should be only a second option for patients with T1 CRC, namely, those solely in clearly low-risk situations or those with distinct comorbidities.

Despite the growing expertise in colonoscopy, it remains subject to complications. The previously published rate of colonoscopic perforation is 0.82 per 1000 examinations. The objective of this study was to describe the experience and management of colonoscopic perforations. A retrospective review of cases from a database of surgical complications was searched for perforations postcolonoscopy from January 1, 2001, to December 31, 2010 at a 527-bed community teaching hospital. Eighteen patients were identified, 11 of whom underwent examination at our institution. Ages ranged from 40 to 91 years with a mean age of 71 years. Eleven of the 18 patients were female and seven were male. Main outcome measures were treatment approach, treatment complications, and mortality. A total of 18 patients were identified in this database. Of these 18 patients, 11 underwent colonoscopy at our institution. During the studied time period, 7578 colonoscopies were performed at our hospital. The majority of the perforations were located in the rectosigmoid colon. Seventeen patients were treated with surgical exploration of the abdomen. Ten patients experienced complications postoperatively. There were two deaths in our series. Only cases in which the colonoscopy was performed at our institution were used when making incidence calculations. The incidence of perforation in our series was significantly higher than previously reported rates. When the perforation was discovered and treated within 24 hours, the patient was rescued. Timely recognition of surgical complications is critical in preventing patient mortality.

Fiberoptic endoscopy is utilized to diagnose and treat a wide variety of gastrointestinal tract diseases and is currently one of the most commonly performed invasive medical procedures. Though generally considered to be safe, the procedure may be associated with serious complications including death. Herein, we correlate the clinical history with the autopsy findings in gastrointestinal endoscopy (GIE) related fatalities that were reported to the New York City Medical Examiner Office over a 5 year period. The complication rate is higher in therapeutic procedures when compared to diagnostic procedures. Though fatalities following iatrogenic complications are four times more common, emphasis is placed on patients who died following a cardiorespiratory event during or immediately following the procedure. Of 41 upper and 36 lower GIE related fatalities, 10 and 9 respectively, fit this category. The comorbidities frequently associated with fatal cardiorespiratory events were: hypertension and obesity with associated cardiac hypertrophy, diabetes mellitus and coronary artery atherosclerosis. For colonoscopies, the approximate incidence of perforation was 0.00625% and the procedure-related fatality rate was 0.014%. The literature on anesthesia for GIE is also discussed.

Background & Aims: Treatment of recurrent Clostridium difficile infection (CDI) with antibiotics leads to recurrences in up to 50% of patients. We investigated the efficacy of fecal transplantation in treatment of recurrent CDI., Methods: We reviewed records from 70 patients with recurrent CDI who had undergone fecal transplantation. Fecal transplantation was performed at colonoscopy by infusing fresh donor feces into cecum. Before transplantation, the patients had whole-bowel lavage with polyethylene glycol solution. Clinical failure was defined as persistent or recurrent symptoms and signs, and a need for new therapy., Results: During the first 12 weeks after fecal transplantation, symptoms resolved in all patients who did not have strain 027 C difficile infections. Of 36 patients with 027 C difficile infection, 32 (89%) had a favorable response; all 4 nonresponders had a pre-existing serious condition, caused by a long-lasting diarrheal disease or comorbidity and subsequently died of colitis. During the first year after transplantation, 4 patients with an initial favorable response had a relapse after receiving antibiotics for unrelated causes; 2 were treated successfully with another fecal transplantation and 2 with antibiotics for CDI. Ten patients died of unrelated illnesses within 1 year after transplantation. No immediate complications of fecal transplantation were observed., Conclusions: Fecal transplantation through colonoscopy seems to be an effective treatment for recurrent CDI and also for recurrent CDI caused by the virulent C difficile 027 strain., (Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Introduction: The number of malpractice claims against physicians and health institutes in Israel is increasing continuously, as in the rest of the Western world. This trend became a serious financial burden., Aim: In this study we analyzed reports of gastroenterologists on colonoscopy adverse events to the medical malpractice insurer, as well as complaint/demand for compensation from patients represented by lawyers, between 1 January 2000 and 31 December 2006., Methods: All the reports of physicians associated with colonoscopy adverse events from health institutes covered by Madanes Insurance Group were analyzed and summarized using a specially designed questionnaire. Clinical and epidemiological details about the patients, procedures, and adverse events were coded into an excel sheet, discussed, and evaluated., Results: One hundred and two cases of colonoscopy adverse events were reported. There were 48 cases of men (47.1%) and the average age was 69.9±12.90 years. In this period of time 252 064 colonoscopies were performed by the institutes in the sampling frame, and the number of adverse events was on average 4.0 (between 2.8 and 6.2) for 10 000 colonoscopies. The difference between the years was not statistically significant. Perforation occurred in one of 2864 procedures, bleeding in one of 29 007 procedures, and respiratory complications in one of 50 412 procedures., Conclusion: This is the first study in Israel based on physicians' reports of colonoscopic adverse events. The picture is optimistic, as the rate of complications is low, and the data encourage early detection and reporting.

Current cancer screening recommendations often apply coarse age cutoffs for screening requirements without regard to predicted life expectancy. Using these cutoffs, healthier older patients may be under-screened, and sicker younger patients may be screened too often. Mortality risk classification using EHR data could be used to tailor screening reminders to physicians in ways that better align screening recommendations with patients who are more likely to live long enough to benefit from early detection. We have evaluated the performance of an existing prognostic index for 4-year mortality using data readily available in the electronic health record (EHR), and investigated the effect of the index in retrospective cohorts of adults age 65 and older undergoing screening colonoscopy. Risk scores in this adaptation of a four-year prognostic index were found to be associated with actual death rates and consistent with mortality rates from a national sample. Our results demonstrate that data extracted from electronic health records can be used to classify mortality risk. With improvements, including extension to a 5-year mortality model with inclusion of additional variables and extension of variable definitions, informatics methods to implement mortality models may prove to be clinically useful in tailoring screening guidelines.

Purpose: Colonoscopy is currently a standard and widespread technique used in screening for colorectal cancer. Iatrogenic colonic perforation during colonoscopy is an unfortunate complication that can induce significant morbidity and even death. Here, we reviewed the clinical results of iatrogenic colonoscopic perforation in our hospital., Methods: This was a retrospective review of 35,186 colonoscopies performed in the Tri-Service General Hospital, Taipei, Taiwan from January 1998 to December 2007. Patient demographic data, indications, comorbidities, operative history, perforation site, time of diagnosis, management, complications, hospital stay, and outcomes were recorded., Results: In this 10-year period, 23 cases of iatrogenic colonic perforation were recorded (0.065%) affecting 11 men and 12 women. The mean age was 71.2 years. There were 13 patients in American Society of Anesthesiology (ASA) classifications 1 or 2 (low anesthetic risk, group A), and ten patients in ASA classes 3 or 4 (high anesthetic risk, group B). The mean hospital stay was 12 days in group A versus 23.5 days in group B (P = 0.002). Moreover, four patients in group B died (17%; P = 0.024)., Conclusion: Colonoscopy-related perforation can progress to peritonitis and sepsis, resulting in serious morbidity or death. High-anesthetic risk patients with colonic perforation have a longer hospital stay and a poor prognosis. Hence, patients need to be informed of the complications of colonoscopy, and clinicians must be cautioned about the potential problems for patients with a high-anesthetic risk when performing the procedure.

Background and Aims: Endoscopic resection of large colorectal neoplasms is increasingly being used as an alternative to surgery. However data on failure rates, safety and long-term outcomes remain limited. The aim of the study was to report short- and long-term outcomes from endoscopic resection of large colorectal neoplasms from a single centre and use a model to predict mortality had surgery been performed., Methods: Consecutive patients referred for endoscopic resection of large (> or = 20 mm) colorectal neoplasms from January 2001 to February 2008 were included. Resection details were recorded in a prospectively maintained database. Data was collected on 30-day complication rates, and follow-up colonoscopy findings. The Colorectal-POSSUM score was used to estimate mortality from open surgery., Results: There were 154 large neoplasms in 140 patients. Mean age was 68 years (range 22-94). Mean neoplasm size was 26 mm (range 20-80 mm, 24 > or = 40 mm). Complete endoscopic removal was achieved in 95% of cases. Twenty patients were referred for surgery (14%). In the endoscopy group, there were no deaths within 30 days. Twelve patients had a complication including two perforations. Endoscopic follow-up data was available in 90% of cases and five patients (4%) were found to have residual adenoma that was treated endoscopically with subsequent clearance. If surgery had been performed, the mean predicted mortality was 2.2% (range 0.5-10%). There were two deaths (10%) in patients who underwent elective surgery within 30 days., Conclusion: Endoscopic resection of large colorectal neoplasms is safe and effective even for very large benign neoplasms. When the lesion is endoscopically resectable this should be the preferred treatment.

Background: Clinical outcomes are increasingly subject to objective assessment and professional accountability. Informed consent relies on accurate estimation of operative risk. Current scoring systems for assessment of operative mortality after colorectal surgery (CRS) almost uniformly report 30-day mortality and may not represent true risk., Design: Prospective cohort., Setting: University-affiliated Veterans Affairs Medical Center., Patients: All patients who underwent resections of the colon and/or rectum (as the principal operation) at a single hospital whose data are captured in the Veterans Affairs National Surgical Quality Improvement Program (VA-NSQIP) database from January 1, 2000, through December 31, 2006., Main Outcome Measures: Mortality at 30 days and 90 days., Results: The VA-NSQIP cohort included 186 patients who underwent CRS, including 148 patients who underwent elective procedures (79.6%) and 38 patients who underwent emergency procedures (20.4%). All but 8 patients were men, with a median age of 67 years (range, 26-92 years). Laparoscopic operations comprised 24.2% and open operations comprised 75.8%. Most (60.8%) were performed for neoplasms. The actual 30-day mortality rates (all, elective, and emergency procedures) were 4.3%, 1.4%, and 15.8%, respectively. These rates closely mirrored the calculated VA-NSQIP risk-adjusted observed-to-expected ratio for 30-day mortality (4.8%, 1.8%, and 18.2%, respectively). However, mortality at 90 days increased substantially to 9.1%, 4.1%, and 28.9%, respectively., Conclusion: The 30-day mortality significantly underreports the true risk of death after CRS. The 90-day mortality rate should be included as a standard outcome measure after CRS because it serves as a better estimation of risk for counseling patients.

Background: Many patients with quiescent ulcerative colitis (UC) experience relapse. However, clinical and conventional colonoscopic signs are inadequate for predicting relapse. This study's aim was to investigate the effectiveness of magnifying colonoscopy in predicting relapse in patients with quiescent UC and to evaluate the association of the findings of magnifying colonoscopy with the histological findings., Methods: Magnifying colonoscopy was performed in 57 patients with clinical and endoscopic inactive UC. Patients were divided into 3 groups according to the findings of magnifying colonoscopy as MR (magnify-regular), MI (magnify-irregular), and MD (magnify-defect). Their subsequent clinical course was compared to assess the clinical usefulness of magnifying observation in predicting relapse. We also compared histological findings according to Riley's criteria to each finding of magnifying colonoscopy., Results: Within 12 months, 1 of 18 patients (6.7%), 10 of 22 patients (45.5%), and 12 of 17 patients (70.6%) with findings of magnifying colonoscopy of MR, MI, and MD, respectively, experienced relapse. The MR group had a significantly low relapse rate compared with the MD and MI groups (P = 0.016, P = 0.002). When histological findings were compared with the findings of magnifying colonoscopy, the mean score of each variable, such as acute inflammatory cell infiltrate, chronic inflammatory cell infiltrate, and crypt architectural irregularities was significantly lower in the MR group than in the MD and MI groups., Conclusions: The findings of magnifying colonoscopy in patients with quiescent UC is useful for predicting relapse and is associated with histological grade of inflammation.

Transanal endoscopic microsurgery (TEM) is a minimally invasive surgical technique that was developed more than two decades ago to manage distal colorectal neoplasias. The aim of the current study was to present a prospective review of 7 years of experience in using this equipment. All patients undergoing TEM between 1999 and 2007 were prospectively evaluated. Patients underwent regular endoscopic follow up. Cumulative incidence probability analysis was used to calculate rates of recurrence. The study involved 232 patients, median age 68 years (interquartile range (IQR), 37-90). The median neoplasia area was 12 cm(2) (IQR, 6-25 cm(2)) and the median height above the anal verge was 9 cm (IQR, 3-17 cm). Histology indicated 128 adenomas, 52 carcinomas in situ, and 52 adenocarcinomas. The median postoperative stay was 1 day (IQR, 1-3 days). There was one (0.5%) unplanned return to theatre and no postoperative deaths. Sixteen patients (6.9%) underwent more radical surgical procedures following the identification of carcinoma in the resected specimen. During a median follow up of 4.2 years (IQR, 2.6-6.2 years), the 5-year cumulative incidence for local recurrence for benign pathology was 3.1% (95% confidence interval (CI): 1.2-6.7%, n = 180) and for cancers managed primarily by TEM excision it was 8.5% (95%CI: 1.4-23.9%, n = 36). TEM is an excellent treatment modality for benign rectal neoplasias of any size, and in any location. TEM is an oncologically inferior treatment for rectal cancer, however, when compared to more radical treatments. Its principal advantage in this setting is that it is associated with relatively minimal morbidity and mortality.

Aspiration of gastric contents is a major complication in relation with the practice of anaesthesia. The present article is aimed at describing detailed data related to aspiration which were obtained during the French national survey on anaesthesia-related mortality conducted by both Sfar and CépiDC-Inserm. Information regarding methods of the survey and the main results has been previously published. In brief, the first part of the survey described the number and characteristics of anaesthetic procedures performed in 1996 (denominator). The second survey analysed deaths related to anaesthesia which were identified from death certificates of the calendar year 1999. Because of the numerical importance of aspiration among the causes of deaths, a secondary analysis was undertaken to assess into details factors leading to the occurrence of this complication. Eighty-three cases of death were found related to aspiration, i.e. one-fifth of deaths related completely or partially to anaesthesia, implying a death rate of one for 221,368 general anaesthetic procedures or 4.5 x 10(-6) (95% IC: 0.8 x 10(-6)-14 x 10(-6)). Patients involved were all in a severe clinical condition (ASA> or =3: 92%), very old and often scheduled for urgent abdominal surgery. Two cases of death occurred during colonoscopy but none in obstetric patients. Aspiration almost always occurred during induction of anaesthesia. Analysis of practice patterns disclosed significant deviations from recommendations. French anaesthetists should voluntarily move through a personal and active process toward an improvement of their practice to reduce the incidence of aspiration.

This study explores associations between patient outcomes (7- and 30-day hospitalization and mortality) and healthcare provider (physician and facility) volumes of outpatient colonoscopy, cataract removal, and upper gastrointestinal endoscopy performed in outpatient surgical settings in Florida. Findings indicate that patients treated by high-volume physicians or facilities had lower adjusted odds ratios for hospitalizations and mortality. When physician and facility volume were assessed simultaneously, physician volume accounted for larger effects than facility volume in hospitalization models. When assessing both physician and facility volume together for mortality, facility volume was a stronger predictor of mortality outcomes at 30 days. Further examinations of associations of outpatient physician and facility volumes and patient outcomes are suggested.

Aim: To study the availability and quality of adult and paediatric colonoscopy in three National Health Service (NHS) regions., Method: A prospective four month study of colonoscopies in North East Thames, West Midlands, and East Anglia., Patients: Subjects undergoing colonoscopy in 68 endoscopy units., Results: A total of 9223 colonoscopies were studied. The mean number of colonoscopies performed over the four month period was 142 in district general hospitals and 213 in teaching hospitals. Intravenous sedation was administered in 94.6% of procedures, but 2.2% and 11.4% of "at risk" patients did not have continuous venous access or did not receive supplemental oxygen, respectively. Caecal intubation was recorded in 76.9% of procedures but the adjusted caecal intubation rate was only 56.9%. Reasons for failing to reach the caecum included patient discomfort (34.7%), looping (29.7%), and poor bowel preparation (19.6%). A normal colonoscopy was reported in 42.1%. The most common diagnosis was polyps (22.5%) followed by diverticular disease (14.9%). Inflammatory bowel disease was recorded in 13.9% and carcinoma in 3.8%. Only half of the patients remembered being told of possible adverse events prior to the procedure. Rectal bleeding requiring admission following colonoscopy was reported in six patients. The overall perforation rate was 1:769 and colonoscopy was considered a possible factor in six deaths occurring within 30 days of the procedure. Only 17.0% of colonoscopists had received supervised training for their first 100 colonoscopies and only 39.3% had attended a training course., Conclusion: There is serious under provision of colonoscopy service in most NHS hospitals. Endoscopy sedation guidelines are not always adhered to and there is a wide variation in practice between units. Colonoscopy is often incomplete and does not achieve the target 90% caecal intubation rate. Serious complications of colonoscopy were comparable with previous studies. Training in colonoscopy is often inadequate and improved practice should result from better training.

Background: Quality assurance is an important part of health-care delivery. With the high level of awareness relating to adverse events from medical care, demonstration of a high standard of practice in gastroenterology is desirable., Aims: To determine the incidence of significant complications or death within 30 days of an outpatient colonoscopy, and confirm that these are in keeping with international standards., Methods: A retrospective audit of linked endoscopy and other hospital databases and selected medical records was carried out, based on reports of 30,463 colonoscopies performed between 5 September 1989 and 31 December 1999 in the three Western Australian public teaching hospitals., Results: A total of 23,508 colonoscopies was performed on an outpatient basis between 5 September 1989 and 31 December 1999. Post-procedural complications identified (and incidence) were: bleeding episodes 49 (0.21%), colonic perforation 23 (0.1%), abdominal pain 22 (0.09%), and others 19 (0.08%). A total of 196 patients died within 30 days of undergoing colonoscopy (0.83%), although only three deaths were attributable to the procedure itself (incidence 0.01%). Two were inpatients at the time of the procedure (outpatient mortality rate 0.004%). The combined incidence of bleeding and perforation was not significantly different between consultant endoscopists and unassisted trainees (incidence 0.21% vs 0.20%, P=0.98)., Conclusions: The incidence of bleeding and perforation is similar to other reported series and reflects procedures performed by personnel with a wide range of endoscopic experience. The incidence of complications was not greater for trainees compared with consultant endoscopists. All bleeding episodes and the majority of perforations were associated with a therapeutic intervention. Diagnostic colonoscopy in particular is a very safe procedure.

If curation is intended for rectal cancer, total mesorectal excision with autonomic nerve preservation (TME) is the gold standard. Transanal resection is tempting because of low mortality and morbidity rates. However, inferior tumour control, provoked by the limitations of the technique, resulted in its cautious application and use mainly for palliation. Transanal endoscopic microsurgery (TEM) is a minimal invasive technique for the local resection of rectal tumours. It is a one-port system, introduced transanally. An optical system with a 3D-view, 6-fold magnification and resolution as the human eye, together with the creation of a stabile pneumorectum, and specially designed instruments allow full-thickness excision under excellent view and a proper histological examination. The technique can also be applied for larger and more proximal tumours. Mortality, morbidity as well as incomplete excision rates are minimal. Local recurrence and survival rates seem comparable to TME in early rectal cancer. TEM is the method of choice when local resection of rectal cancer is indicated. Results justify a re-evaluation of the indications for the local excision of rectal cancer with a curative intent.

Background: Although most diagnostic GI endoscopic procedures in Germany are performed on an outpatient basis, there is no large-scale prospective evaluation of complication rates., Methods: Ninety-four gastroenterologists and internists from all regions of Germany recorded the number of EGD, colonoscopies, and polypectomies performed over a period of 1 year. All serious complications occurring in relation to the procedure, including the use of medication, were recorded in a structured protocol., Results: A total of 110,469 EGDs, 82,416 colonoscopies, and 14,249 polypectomies were evaluated. The "reach-the-cecum-rate" was 97% (median). The overall complication rates for EGD, colonoscopy, and polypectomy were low compared with published data (0.009%, 0.02%, and 0.36%, respectively). The perforation rates were 0.0009%, 0.005%, and 0.06%, respectively, the rates of significant hemorrhage 0.002%, 0.001%, and 0.26%, respectively, and the mortality rates 0.0009%, 0.001%, and 0.007%, respectively. The rates of cardiorespiratory complications associated with EGD and colonoscopy were 0.005% and 0.01%, respectively. The overall complication rate for all procedures (diagnostic and therapeutic) was lower for gastroenterologists (1 per 5155 procedures) than internists (1 per 1539 procedures). Most of the adverse events associated with diagnostic endoscopy were attributable to use of medication. The severity score ranged from 2 to 5 for most of the adverse events occurring as a result of diagnostic procedures and 2 to 50 for polypectomy. The severity sum score per 10,000 procedures was 26 for EGD, 67 for colonoscopy, and 1185 for polypectomy., Conclusions: Outpatient endoscopy performed in practice settings by German gastroenterologists and internists is safe. The low complication rates may partly be explained by the high degree of experience resulting from the larger numbers of procedures performed relative to the numbers performed by gastroenterologists in hospitals and in other countries.

Background: Laparoscopic colon anastomosis are technically demanding. A new technique for colon resection and anastomosis using a combined laparoendoscopic approach is presented., Methods: In 10 pigs, pneumoperitoneum was induced and 5 trocars were placed. A sigmoid segment was isolated; a vein stripper was inserted from the anus, and the head was secured with a tie; the segment was intussuscepted pulling the stripper out; 4 seromuscular sutures were placed at the anastomotic site and fibrin glue was spread all around; an electrical wire loop, introduced via a colonoscope, was used to resect the intussuscepted segment that was removed from the anus., Results: All animals but one survived until sacrifice at 30, 60, 90, and 120 days. Macroscopically, the anastomosis appeared well healed; microscopically, after 90 days, there was a complete restitutio ad integrum of the intestinal wall., Conclusions: This technique is feasible and quick; it could be used clinically in small tumors not removable endoscopically.

The diagnostic and therapeutic benefits of colonoscopy are well known but most large-scale surveys, especially those involving multiple centres, may underestimate the range and incidence of complications. The detailed records of 5000 colonoscopies in a specialist unit have been analysed and conclusions drawn which may help to make the procedure safer. The incidence of haemorrhage was 1% and bowel perforation 0.1%. All the major haemorrhages occurred during polypectomies over 2 cm in size. Secondary haemorrhage was an unpredictable occurrence, one to 14 days later. Three deaths followed colonoscopy: one cardiorespiratory death was related to oversedation; a second was due to mismanaged ischaemic colitis developing two days after traumatic instrumentation, and the third was due to peritonitis. Minor complications included thrombophlebitis, abdominal distension, and vasovagal episodes. Because of experience during the first half of the series and also due to improvements in instrumentation, the complication rate of the later part of the series was halved. Recommendations include the avoidance of oversedation, review of previous barium enema films so as to be aware of large polyps which are more likely to bleed, and the recognition of situations where perforation or septicaemia is likely to occur.