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PURPOSE Resectable non–small-cell lung cancer (NSCLC) with a high probability of mediastinal nodal involvement requires mediastinal staging by endosonography and, in the absence of nodal metastases, confirmatory mediastinoscopy according to current guidelines. However, randomized data regarding immediate lung tumor resection after systematic endosonography versus additional confirmatory mediastinoscopy before resection are lacking. METHODS Patients with (suspected) resectable NSCLC and an indication for mediastinal staging after negative systematic endosonography were randomly assigned to immediate lung tumor resection or confirmatory mediastinoscopy followed by tumor resection. The primary outcome in this noninferiority trial (noninferiority margin of 8% that previously showed to not compromise survival, Pnoninferior < .0250) was the presence of unforeseen N2 disease after tumor resection with lymph node dissection. Secondary outcomes were 30-day major morbidity and mortality. RESULTS Between July 17, 2017, and October 5, 2020, 360 patients were randomly assigned, 178 to immediate lung tumor resection (seven dropouts) and 182 to confirmatory mediastinoscopy first (seven dropouts before and six after mediastinoscopy). Mediastinoscopy detected metastases in 8.0% (14/175; 95% CI, 4.8 to 13.0) of patients. Unforeseen N2 rate after immediate resection (8.8%) was noninferior compared with mediastinoscopy first (7.7%) in both intention-to-treat (Δ, 1.03%; UL 95% CIΔ, 7.2%; Pnoninferior = .0144) and per-protocol analyses (Δ, 0.83%; UL 95% CIΔ, 7.3%; Pnoninferior = .0157). Major morbidity and 30-day mortality was 12.9% after immediate resection versus 15.4% after mediastinoscopy first ( P = .4940). CONCLUSION On the basis of our chosen noninferiority margin in the rate of unforeseen N2, confirmatory mediastinoscopy after negative systematic endosonography can be omitted in patients with resectable NSCLC and an indication for mediastinal staging.

IntroductionGuidelines for invasive mediastinal nodal staging in resectable nonsmall cell lung cancer (NSCLC) have changed over the years. The aims of this study were to describe trends in invasive staging and unforeseen N2 (uN2) and to assess a potential effect on overall survival.MethodsA nationwide Dutch cohort study included all clinical stage IA–IIIB NSCLC patients primarily treated by surgical resection between 2005 and 2017 (n=22 555). We assessed trends in invasive nodal staging (mediastinoscopy 2005–2017; endosonography 2011–2017), uN2 and overall survival and compared outcomes in the entire group and in clinical nodal stage (cN)1–3 patients with or without invasive staging.ResultsAn overall increase in invasive nodal staging from 26% in 2005 to 40% in 2017 was found (pversus39% in patients without invasive staging (p=0.12).ConclusionA significant increase in invasive mediastinal nodal staging in patients with resectable NSCLC was found between 2011 and 2017 in the Netherlands. Increasing use of less invasive endosonography prior to (or as a substitute for) surgical staging did not lead to more cases of uN2. Performance of invasive staging indicated a possible overall survival benefit in patients with cN1–3 disease.

OBJECTIVES: Invasive mediastinal staging is advised by guidelines in patients with resectable non-small cell lung cancer (NSCLC) and suspicious lymph nodes (cN1-3) or for central, FDG-non-avid or peripheral tumours >3 cm. Our objective was to assess current guideline adherence and consequent unforeseen N2 disease (uN2) in NSCLC patients having various indications for mediastinal staging.MATERIALS AND METHODS: We analysed the Dutch Lung Cancer Audit - Surgery data of all patients who underwent a primary lung resection with lymph node dissection for NSCLC in 2017-2018. Based on the 2015 ESTS-ERS-ESGE guideline we assessed the use of initial endosonography and confirmatory mediastinoscopy as well as uN2 rates.RESULTS: A total of 2238 patients were analysed. 43 % (95 %-CI: 41-45) underwent initial endosonography followed by a confirmatory mediastinoscopy in 44 % (95 %-CI:40-47) of them, resulting in a 19 % (95 %-CI: 17-20) rate of properly staged patient according to the guidelines. uN2 was demonstrated in 12.5 % (95 %-CI: 9.7-16.0) of correctly staged patients compared to 10.9 % (95 %-CI: 9.6-12.4) who were not (p = .36). The highest uN2 rate was found in cN1-3 patients who were not staged (23.0 %, 95 %-CI: 16.4-31.2) compared to 13.0 % (95 %-CI: 9.7-17.1) who were (p = .01).CONCLUSION: Guideline adherence in Dutch NSCLC patients with an indication for invasive mediastinal staging is poor. The highest uN2 rate was found in unstaged cN1-3 patients, suggesting that this subgroup may benefit from an appropriate staging conform guidelines.

Objectives: Mediastinal lymph node staging of NSCLC by initial endosonography and confirmatory mediastinoscopy is recommended by the European guideline. We assessed guideline adherence on mediastinal staging, whether staging procedures were performed systematically and unforeseen N2 rates following staging by endosonography with or without confirmatory mediastinoscopy.Material and Methods: We performed a multicentre (n = 6) retrospective analysis of NSCLC patients without distant metastases, who were surgical candidates and had an indication for mediastinal staging in the year 2015. All patients who underwent EBUS, EUS and/or mediastinoscopy were included. Surgical lymph node dissection was the reference standard. Guideline adherence was based on the 2014 ESTS guideline.Results: 330 consecutive patients (mean age 69 years; 61% male) were included. The overall prevalence of N2/N3 disease was 42%. Initial mediastinal staging by endosonography was done in 84% (277/330; range among centres 71-100%; p Conclusion: Although adherence to the European NSCLC mediastinal staging guideline on initial use of endosonography was good, 30% of endosonography procedures were performed insufficiently. Confirmatory mediastinoscopy following negative endosonography was frequently omitted. Significant variability was found among participating centres regarding staging strategy and systematic performance of procedures. However, unforeseen N2 rates after mediastinal staging by endosonography with and without confirmatory mediastinoscopy were comparable.

BackgroundSufficient pain control and rapid mobilisation after VATS are important to enhance recovery and prevent complications. Thoracic epidural analgesia (TEA) is the gold standard, but failure rates of 9–30% have been described. In addition, TEA reduces patient mobilisation and bladder function. Subpleural continuous analgesia (SCA) is a regional analgesic technique that is placed under direct thoracoscopic vision and is not associated with the mentioned disadvantages of TEA. The objective of this study was to assess surgical feasibility, pain control and patient satisfaction of SCA.MethodsObservational pilot study in patients who underwent VATS pulmonary resection and received SCA (n = 23). Pain scores (numeric rating scale 0–10) and patient satisfaction (5-point Likert scale) were collected on postoperative day (POD) 0–3. Secondary outcomes were the period of urinary catheter use and period to full mobilisation.ResultsPlacement of the subpleural catheter took an average of 11 min (SD 5) and was successful in all patients. Pain scores on POD 0–3 were 1.2 (SD 1.2), 2.0 (SD 1.9), 1.7 (SD 1.5) and 1.2 (SD 1.1) respectively. On POD 0–3 at least 79% of patients were satisfied or very satisfied on pain relief and mobilisation. The duration of subpleural continuous analgesia was 4 days (IQR 3–5, range 2–11). Urinary catheters were used zero days (IQR 0–1, range 0–6) and full mobilisation was achieved on POD 2 (IQR 1–2, range 1–6).ConclusionSubpleural continuous analgesia in VATS pulmonary resection is feasible and provides adequate pain control and good patient satisfaction.Trial registrationThis pilot study was not registered in a trial register.

Introduction: Endosonography is recommended over mediastinoscopy as initial mediastinal staging procedure in NSCLC. In case of N0-1 at E(B)US, guidelines advise confirmatory mediastinoscopy to rule out false-negatives. The routine use of confirmatory mediastinoscopy is under debate. Aims: To asses: 1) Variability in performance of confirmatory mediastinoscopy following N0-1 at E(B)US 2) False negative rate of E(B)US 3) Unforeseen N2-3 disease after E(B)US alone vs E(B)US followed by mediastinoscopy Methods: Multicenter (n=5) retrospective analysis of NSCLC patients without distant metastases and an indication for mediastinal staging in the year 2015. Surgical lymph node dissection was the reference standard for accuracy. Guideline adherence was based on the 2014 ESTS guideline. Results: 255 consecutive patients (mean age 68 years, 60% male) were included with a pathologically proven N2-3 prevalence of 38%. 222 patients (87%) underwent endosonography (181 EBUS, 31 EUS, 10 EBUS+EUS) and 33 mediastinoscopy as initial staging procedure. False negative rate of E(B)US for N2-3 was 6.5%. Of the 139 patients (63%) with N0-1 after E(B)US, only 48 (35%) underwent confirmatory mediastinoscopy (range between hospitals 0-100%) and additional N2-3 was diagnosed in 3 patients (6.3%). Unforeseen N2-3 rate after E(B)US alone was 8.8% vs 9.1% after E(B)US followed by mediastinoscopy. Conclusion: Adherence to the ESTS guideline regarding initial E(B)US evaluation is good (87%), however confirmatory mediastinoscopy is frequently omitted (65%). Unforeseen N2 rates after E(B)US alone and after E(B)US followed by mediastinoscopy were similar and therefore the routine use of confirmatory mediastinoscopy needs to be evaluated.

Background and Aims: Large non-pedunculated rectal polyps are most commonly resected by endoscopic mucosal resection (EMR) or transanal endoscopic microsurgery (TEM). Despite pre-procedural diagnostics, unexpected rectal cancer is incidentally encountered within the resected specimen. This study aimed to compare the diagnostic assessment and procedural characteristics of lesions with and without unexpected submucosal invasion. Methods: A post-hoc analysis of a multicenter randomized trial (TREND study) was performed in which patients with a non-pedunculated rectal polyp of >= 3 cm without endoscopic suspicion of invasive growth were randomized between EMR and TEM. Results: Unexpected rectal cancer was detected in 13% (27/203) of patients; 15 after EMR and 12 after TEM. Most consisted of low-risk T1 cancers (78%, n = 18). There were no differences in the diagnostic assessment between lesions with and without unexpected submucosal invasion. Diagnostic biopsies revealed similar rates of high-grade dysplasia (28%[7/25] vs 18% [26/144]). When compared with EMR of adenomas, EMR procedures of unexpected cancers had a lower success rate of submucosal lifting (60% vs 93%, P

Background & Aims Endoscopic trimodal imaging (ETMI) is a novel endoscopic technique that combines high-resolution endoscopy (HRE), autofluorescence imaging (AFI), and narrow-band imaging (NBI) that has only been studied in academic settings. We performed a randomized, controlled trial in a nonacademic setting to compare ETMI with standard video endoscopy (SVE) in the detection and differentiation of colorectal lesions. Methods The study included 234 patients scheduled to receive colonoscopy who were randomly assigned to undergo a colonoscopy in tandem with either ETMI or SVE. In the ETMI group (n = 118), first examination was performed using HRE, followed by AFI. In the other group, both examinations were performed using SVE (n = 116). In the ETMI group, detected lesions were differentiated using AFI and NBI. Results In the ETMI group, 87 adenomas were detected in the first examination (with HRE), and then 34 adenomas were detected during second inspection (with AFI). In the SVE group, 79 adenomas were detected during the first inspection, and then 33 adenomas were detected during the second inspection. Adenoma detection rates did not differ significantly between the 2 groups (ETMI: 1.03 vs SVE: 0.97, P = .360). The adenoma miss-rate was 29% for HRE and 28% for SVE. The sensitivity, specificity, and accuracy of NBI in differentiating adenomas from nonadenomatous lesions were 87%, 63%, and 75%, respectively; corresponding values for AFI were 90%, 37%, and 62%, respectively. Conclusions In a nonacademic setting, ETMI did not improve the detection rate for adenomas compared with SVE. NBI and AFI each differentiated colonic lesions with high levels of sensitivity but low levels of specificity.

Background: Natural orifice transluminal endoscopic surgery peritoneoscopy may be able to replace laparoscopic peritoneoscopy (LAP) for staging of GI malignancies if it is proven to be equally accurate and safe. Objective: To compare transgastric peritoneoscopy (TGP) and transcolonic peritoneoscopy (TCP) to LAP, pairwise, in a randomized, blinded (to location and number of beads) human cadaver model with simulated peritoneal metastases. Design: Metastases were simulated by 2.5-mm, color-coded beads, which were placed into the peritoneal cavity via an open approach. In previous porcine experiments, LAP resulted in a yield of 95%. By using a noninferiority design with a margin of equivalence of 15%, we needed a sample size of 34 beads for 80% power. Randomization was performed for number and location of beads. Eighteen experiments were performed on 6 fresh-frozen human cadavers. Setting: Experimental surgical laboratory. Intervention: LAP, TGP, and TCP were performed in randomized order by one of two surgeons/endoscopists blinded for location and number of beads. Main Outcome Measurements: Number of beads detected and touched. Results: LAP found and touched 33 beads (yield 97%), TGP 26 beads (76%; difference in yield vs LAP was -20.5 [95% CI, -26.3 to -9.27]), and TCP 29 beads (85%; difference in yield vs LAP was -11.8 [95% CI, -14.6 to 4.98]). Beads that were missed were mostly located at the inferior liver surface: TGP missed 6 of 9 of these beads (67%), TCP 4 of 9 (44%). Limitations: Cadaver model. Conclusion: In this prospective, blinded, comparative trial in a human cadaver model, TCP was comparable to LAP in detecting simulated metastases. TGP was inferior to LAP. Future development should focus on improved visualization of the inferior surface of the liver. (Gastrointest Endosc 2010;72:1027-33.)

In the past decades, the perspective of diagnostic endoscopy has changed from diagnosing clearly visible advanced abnormalities to the detection of more subtle abnormalities, allowing treatment at an early and curable stage. Endoscopic surveillance is increasingly practiced for patients known to be at risk for development of esophageal and gastric cancers. Despite the improvement in endoscopic image quality, the endoscopic visualization of early neoplasia can still be difficult, which may lead to neoplasia miss rates and interval cancers between successive endoscopies. New imaging modalities, such as narrow-band imaging (NBI), may allow for better detection of these early neoplastic lesions and may thus improve the effectiveness of endoscopic surveillance and screening. NBI uses short wavelength light (essentially blue light) for tissue excitation. Blue light only penetrates superficially into the tissue and is highly absorbed by hemoglobin, which causes NBI to highlight mucosal surface patterns and microvascular details. This enhanced contrast provided by NBI can theoretically improve the detection of small and subtle mucosal lesions. In addition to a possible effect on detection, NBI also has the potential for endoscopic differentiation of lesions (ie, ‘‘endopathology’’). Accurate differentiation of lesions may enable immediate decision making during the initial endoscopic procedure: presumed (pre)malignant lesions can be immediately removed by endoscopic resection, whereas innocent nonneoplastic lesions may be left in situ. In addition to the early detection and differentiation of possible premalignant lesions, NBI may also be useful for identification of nonneoplastic conditions such as Helicobacter pylori gastritis or minimal-change reflux esophagitis. In most countries, NBI has been commercially available for less than 2 years, but nevertheless the technology is currently widely available throughout the world. This systematic review summarizes the data on the performance and clinical utility of NBI in upper GI endoscopy. The aims of this systematic review were to evaluate the role of NBI in (1) the primary detection of (pre)malignant lesions, (2) the differentiation between neoplastic and nonneoplastic lesions, and (3) other potential indications in upper GI endoscopy.

Background & Aims Endoscopic trimodal imaging (ETMI) incorporates high-resolution endoscopy (HRE) and autofluorescence imaging (AFI) for adenoma detection, and narrow-band imaging (NBI) for differentiation of adenomas from nonneoplastic polyps. The aim of this study was to compare AFI with HRE for adenoma detection and to assess the diagnostic accuracy of NBI for differentiation of polyps. This was a randomized trial of tandem colonoscopies. The study was performed at the Academic Medical Center in Amsterdam. Methods One hundred patients underwent colonoscopy with ETMI. Each colonic segment was examined twice for polyps, once with HRE and once with AFI, in random order per patient. All detected polyps were assessed with NBI for pit pattern and with AFI for color, and subsequently removed. Histopathology served as the gold standard for diagnosis. The main outcome measures of this study were adenoma miss-rates of AFI and HRE, and diagnostic accuracy of NBI and AFI for differentiating adenomas from nonneoplastic polyps. Results Among 50 patients examined with AFI first, 32 adenomas were detected initially. Subsequent inspection with HRE identified 8 additional adenomas. Among 50 patients examined with HRE first, 35 adenomas were detected initially. Successive AFI yielded 14 additional adenomas. The adenoma miss-rates of AFI and HRE therefore were 20% and 29%, respectively ( P = .351). The sensitivity, specificity, and overall accuracy of NBI for differentiation were 90%, 70%, and 79%, respectively; corresponding figures for AFI were 99%, 35%, and 63%, respectively. Conclusions The overall adenoma miss-rate was 25%; AFI did not significantly reduce the adenoma miss-rate compared with HRE. Both NBI and AFI had a disappointing diagnostic accuracy for polyp differentiation, although AFI had a high sensitivity.

Background and study aims: Novel imaging techniques need to be evaluated for their ability to improve the detection of polyps. Critical appraisal of reported studies reveals remarkable differences in study designs, despite their similar objectives. The aim of the current study was to compare frequently used study designs for their required sample size to detect relevant differences in polyp detection rates. Patients and methods: Three commonly reported study designs were compared: design 1, the parallel randomized design; design 2, the randomized cross-over design with direct removal of polyps; and design 3, the randomized cross-over design without direct removal of polyps. A total of five different scenarios were analyzed per study design, representing a variety of clinical settings. Each scenario was repeated 1000 times for each study design and the sample size that produced a significant result per study design in each scenario was recorded. Results: In many scenarios, study design 1 required 10 – 15 times more patients to reach the same statistical power of 80 % compared with study design 2. Further reductions in sample size could be achieved when study design 3 was used, although this design is limited by its impracticality. Conclusions: The randomized parallel design requires a larger sample size to achieve equivalent power to the cross-over design. Researchers should carefully consider whether the latter design could be used instead, as it requires a lower number of subjects, although it may be more cumbersome for patients, endoscopists, and researchers.

Background The Spigelman classification stratifies cancer risk in familial adenomatous polyposis (FAP) patients with duodenal adenomatosis. High-resolution endoscopy (HRE) and narrow-band imaging (NBI) may identify lesions at high risk. Objective To compare HRE and NBI for the detection of duodenal and gastric polyps and to characterize duodenal adenomas harboring advanced histology with HRE and NBI. Design Prospective, nonrandomized, comparative study. Retrospective image evaluation study. Setting Tertiary-care center. Patients Thirty-seven FAP patients undergoing surveillance upper endoscopies. Intervention HRE endoscopy was followed by NBI. The number of gastric polyps and Spigelman staging were compared. Duodenal polyp images were systematically reviewed in a learning and validation phase. Main Outcome Measurements Number of gastric and duodenal polyps detected by HRE and NBI and prevalence of specific endoscopic features in duodenal adenomas with advanced histology. Results NBI did not identify additional gastric polyps but detected more duodenal adenomas in 16 examinations, resulting in upgrades of the Spigelman stage in 2 cases (4.4%). Pictures of 168 duodenal adenomas (44% advanced histology) were assessed. In the learning phase, 3 endoscopic features were associated with advanced histology: white color, enlarged villi, and size ≥1 cm. Only size ≥1 cm was confirmed in the validation phase (odds ratio 3.0; 95% confidence interval, 1.2-7.4). Limitations Nonrandomized study, scant number of high-grade dysplasia adenomas. Conclusion Inspection with NBI did not lead to a clinically relevant upgrade in the Spigelman classification and did not improve the detection of gastric polyps in comparison with HRE. The only endoscopic feature that predicted advanced histology of a duodenal adenoma was size ≥1 cm.

Probe-based confocal laser scanning endomicroscopy (pCLE) enables in-vivo histopathology during ongoing endoscopy. The most frequently used fluorophore is fluorescein sodium administered intravenously. Despite the increased use of pCLE, there are hardly any data on the ideal fluorescein concentration. Therefore, rectal mucosa of pigs was examined after injection (i.v.) of fluorescein as a single bolus (0.1 ml/kg body weight) in different concentrations (0.5%, 1%, 2%, 5%. 10%). Video sequences were recorded after 1, 5 and 60 min. For objective evaluation signal-to-noise ratio (SNR) was computed. For subjective evaluation, video sequences were randomized and blindly evaluated by experienced endo-microscopists. In total, 19037 images were analyzed. The mean SNR increased from the lowest (0.5%; SNR 6.75, range 3.55) to the highest concentration (10%; SNR 9.11, range 3.118). Subjective evaluation demonstrated best image quality with fluorescein concentration of 5%. In conclusion, pCLE shows best results using single injection of IV fluorescein 5%

To evaluate the yield and clinical impact of random biopsies taken during colonoscopic surveillance of patients with longstanding ulcerative colitis (UC). Retrospective analysis of 1,010 colonoscopies performed from 1998 to 2008. Colonoscopy and pathology reports were reviewed to assess the yield and clinical impact of random biopsies. In total, 475 patients with UC who underwent colonoscopy at the Academic Medical Centre Amsterdam were included in this study. The main outcome measures are neoplasia yield per-colonoscopy and clinical impact per-patient of random biopsies. Of all colonoscopies, 466 were performed for surveillance (in 167 patients) during which 11,772 random biopsies were taken (median 29). Overall, neoplasia was detected in 88 colonoscopies (53 patients): in 75 colonoscopies (85%) by targeted biopsies only and in 8 (9.1%) by both targeted and random biopsies. Neoplasia was detected in random biopsies only in five (5.7%) colonoscopies in four (7.5%) patients. Two of these four patients with neoplasia detected only by random biopsies had visible neoplasia in previous colonoscopies. One patient had unifocal low-grade intraepithelial neoplasia (LGIN) that could not be confirmed in three subsequent colonoscopies. The last patient had multifocal LGIN and suspicious appearing ulcerations. Proctocolectomy confirmed the presence of neoplasia. The yield of random biopsies is low whereas UC-associated neoplasia is macroscopically visible in 94% of colonoscopies. During 10-year surveillance, neoplasia was detected in only random biopsies in four patients of whom only one had clinical consequences. The low yield and lack of clinical consequences from random biopsies in this high-risk population raise questions about the necessity and cost-effectiveness of their routine use during UC surveillance

OBJECTIVES: Endoscopic tri-modal imaging incorporates high-resolution white-light endoscopy (HR-WLE), narrow-band imaging (NBI), and autofluorescence imaging (AFI). Combining these advanced techniques may improve endoscopic differentiation between adenomas and non-neoplastic polyps. In this study, we aimed to assess the interobserver variability and accuracy of HR-WLE, NBI, and AFI for polyp differentiation and to evaluate the combined use of AFI and NBI. METHODS: First, still images of 50 polyps (22 adenomas; median 3 mm) were randomly displayed to three experienced and four non-experienced endoscopists. All HR-WLE and NBI images were scored for Kudo classification and AFI images for color. Second, the combined AFI and NBI images were assessed using a newly developed algorithm by six additional non-experienced endoscopists. RESULTS: The outcomes measured were interobserver agreement and diagnostic accuracy using histopathology as reference standard. Experienced endoscopists had better interobserver agreement for NBI (kappa=0.77) than for AFI (kappa=0.33), whereas non-experienced endoscopists had better agreement for AFI (kappa=0.58) than for NBI (kappa=0.33). The accuracies of HR-WLE, NBI, and AFI among experienced endoscopists were 65, 70, and 74, respectively. Figures among non-experienced endoscopists were 57, 63, and 77. The algorithm was associated with a significantly higher accuracy of 85% among all observers (P

Background Recent non-randomized studies suggest that extended endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM). If equally effective, EMR might be a more cost-effective approach as this strategy does not require expensive equipment, general anesthesia and hospital admission. Furthermore, EMR appears to be associated with fewer complications. The aim of this study is to compare the cost-effectiveness and cost-utility of TEM and EMR for the resection of large rectal adenomas. Methods/design Multicenter randomized trial among 15 hospitals in the Netherlands. Patients with a rectal adenoma ≥ 3 cm, located between 1–15 cm ab ano, will be randomized to a TEM- or EMR-treatment strategy. For TEM, patients will be treated under general anesthesia, adenomas will be dissected en-bloc by a full-thickness excision, and patients will be admitted to the hospital. For EMR, no or conscious sedation is used, lesions will be resected through the submucosal plane in a piecemeal fashion, and patients will be discharged from the hospital. Residual adenoma that is visible during the first surveillance endoscopy at 3 months will be removed endoscopically in both treatment strategies and is considered as part of the primary treatment. Primary outcome measure is the proportion of patients with recurrence after 3 months. Secondary outcome measures are: 2) number of days not spent in hospital from initial treatment until 2 years afterwards; 3) major and minor morbidity; 4) disease specific and general quality of life; 5) anorectal function; 6) health care utilization and costs. A cost-effectiveness and cost-utility analysis of EMR against TEM for large rectal adenomas will be performed from a societal perspective with respectively the costs per recurrence free patient and the cost per quality adjusted life year as outcome measures. Based on comparable recurrence rates for TEM and EMR of 3.3% and considering an upper-limit of 10% for EMR to be non-inferior (beta-error 0.2 and one-sided alpha-error 0.05), 89 patients are needed per group. Discussion The TREND study is the first randomized trial evaluating whether TEM or EMR is more cost-effective for the treatment of large rectal adenomas. Trial registration number (trialregister.nl) NTR1422

Background Endoscopic differentiation and removal of potentially premalignant sessile serrated adenomas (SSAs) may be important steps in preventing the development of colorectal cancer in hyperplastic polyposis syndrome (HPS). Objective To assess the value of high-resolution endoscopy, autofluorescence imaging (AFI), and narrow-band imaging (NBI) for differentiating polyps in HPS. Design A prospective polyp series. Setting Single tertiary referral center. Patients and Interventions Seven patients with HPS underwent colonoscopy with endoscopic trimodal imaging, which incorporates high-resolution endoscopy, AFI, and NBI in 1 system. All detected polyps were analyzed with AFI for color and with NBI for Kudo pit pattern and vascular pattern intensity. Main Outcome Measurements The accuracy, sensitivity, and specificity of AFI and NBI in differentiating detected polyps were determined by using histology as the criterion standard. Results A total of 19 hyperplastic polyps (HPs), 32 SSAs, and 15 adenomas were detected. For differentiating SSAs from HPs, AFI color, Kudo pit pattern, and vascular pattern intensity resulted in a diagnostic accuracy of 55%, 55%, and 52%, respectively. For differentiating adenomas from HPs, the accuracy was 65%, 94%, and 90%, respectively. Macroscopically, the combination of a size of 3 mm or larger and a proximal location resulted in the highest accuracy (76%) for differentiating SSAs from HPs. Limitation Small sample size. Conclusion Endoscopic differentiation between HPs and SSAs by using endoscopic trimodal imaging proved unsatisfactory. Differentiation of adenomas from HPs was possible with NBI but not with AFI.

G A A b st ra ct s infliximab. We describe the first case of disseminated mucocutaneous granulomas in a patient with UC receiving infliximab. Case: 19-year-old female with UC in clinical remission, who had been treated with infliximab (10mg/kg/every 8 weeks) for 2 years, presented with multiple skin, nasal and oral lesions developing over the course of three months. The skin lesions were erythematous annular plaques on the right hip, inner thighs and forearms. Multiple ulcers were found in the nasal turbinates and one on the hard palate. Repeat esophagogastroduodenoscopy and colonoscopy at the time of evaluation for these lesions showed mild chronic esophagitis andmild chronic proctitis. She had a normal MRI enterography. Her IBD serology (pANCA positive; ASCA IgA, IgG negative) was also supportive of a diagnosis of UC. Histological examination of the skin biopsy revealed a diffuse interstitial granulomatous infiltrate with lymphocytes and histiocytes. Biopsy of the nasal and oral mucosa revealed a marked submucosal inflammatory infiltrate composed of lymphocytes, plasma cells and eosinophils with granulomas and foci of necrosis. Special stains and cultures for bacteria, fungus and mycobacteria were negative. Evaluation was negative for Cryptococcus, Bordetella henselae, Blastomyces and Histoplasma. Angiotensin I converting enzyme was normal. CT scan of the sinuses and chest radiograph were normal as well. Discussion: Metastatic Crohn's disease, opportunistic infections and granulomatous reaction to infliximab were considered in the differential diagnosis. IGD was the most likely cause of these lesions in our patient. Metastatic Crohn's disease was unlikely given the quiescence of her intestinal disease compared to the activity of the mucocutaneous involvement. Opportunistic infections, which can be fatal in the face of anti-TNF therapy were ruled out by negative cultures. Furthermore, in our patient, her skin and mucosal lesions had significantly improved with no other intervention except for the discontinuation of her anti-TNF therapy. Conclusion: Granulomatous diseases, including IGD, should be considered in the differential diagnosis of annular or ulcerated lesions in the setting of anti TNFtherapy in a patient with IBD.

The pathological signs of the disease showed strong correlation with the CDAI score in MREG (r =0.69). Conclusion: It has been observed that the MRI technique with oral contrast administration is an accurate tool in detecting inflammatory activity. The relatively safe contrast medium and a negligible radiation exposure are the main reasons why MREG should be used as a preferred method for monitoring of patients with Crohn's disease.