The Robotic Colonoscope E-Worm, a New Device to Perform Colonoscopy: Preliminary Report

Abstracts

T1392 Indication of Endoscopic Submucosal Dissection (ESD) for Large Colorectal Tumors Accompanied with Fibrosis in Submucosal Layer Keiko Kudo, Yoshirou Tamegai, Takashi Koike Background and Aims: The safety of endoscopic submucosal dissection (ESD) for colorectal tumors is gradually being established. The possibility of performing ESD for colorectal tumors sometimes depends on the existence of fibrosis in the submucosal layer, rather than only the size and location of the tumor. This study analyzed the causes and endscopic findings of fibrosis in the submucosal layer, in order to establish a therapeutic strategy for such lesions. Patients and Methods: ESD was attempted for 202 cases of colorectal neoplasm. Among these cases, 35 cases were accompanied by submucosal fibrosis. These cases were analyzed from clinico-pathological viewpoint. Results: For the ESD cases, the average lesion size was 31.6mm, and mean operating time was 62.8min . We had only one case with a microperforation (0.5%), which was treated with clipping. Histology showed adenoma in 85, intramucosal cancer in 83, submucosal invasive cancer. Of the 200 cases that had radical endoscopic resection, no tumor recurrence was found after treatment. During the study period, we abandoned ESD in only 2 of the 202 cases, because of severe fibrosis. Among the 35 cases with submucosal fibrosis, 13 cases were considered related to cancer invasion, and 22 cases were unrelated to cancer invasion. We completed en bloc resections for 26 lesions. Seven lesions were finally removed using the piecemeal EMR(Endoscopic Mucosal Resection) procedure because of a high degree of submucosal fibrosis. Therefore the rate of en bloc resection was 74.3%. The fibrosis of non-cancerous origin was caused by inflammation, biopsy, saline injection, and previous inadequate endoscopic treatment. We classified the endoscopic findings of ‘string-like’ or ‘rope-like’ as mild degree. ‘Band-like’ was classified as moderate degree, and ‘screen-like’ was severe degree fibrosis. Otherwise, a white or brown area and abnormal vessels were identified in the cases with submucosal cancer invasion. In the cases with slight submucosal cancer invasion, endoscopic examination showed a rough and string-like fibrosis accompanied by vessels. In cases with massive cancer invasion, endoscopic examination of the fibrous area showed a brown mass accompanied by irregular vessels, and was classified as severe degree. Lesions with fibrosis should be dissected carefully just above the muscularis propria. In cases with a high degree of fibrosis, ESD becomes more difficult because of the risk of severe complications. Conclusion: The tumor accompanied by mild to moderate fibrosis should become a standard indication for ESD. In contrast, ESD is not indicated for cases with a severe degree of fibrosis.

T1394 Usefulness of a New Modified 6-Point Activity Index Compared with Established Indices in the Diagnosis of Endoscopic Activity in Ulcerative Colitis Taro Osada, Toshifumi Ohkusa, Tetsuji Yokoyama, Tomoyoshi Shibuya, Naoto Sakamoto, Kazuko Beppu, Akihito Nagahara, Michiro Otaka, Tatsuo Ogihara, Sumio Watanabe Background: This study evaluated inter- and intra-observer agreement in the assessment of ulcerative colitis (UC) activity using four established indices and a newly-designed Modified 6-point Activity Index, and the importance of observer experience. Method: Two hundred seventy nine endoscopic pictures of inflammatory lesions from 93 UC patients were displayed twice to four expert and four trainee endoscopists, at an interval of one month. Each picture was assessed for inflammatory changes using established indices (Matts, Schroeder [a.k.a. Mayo Score], Baron, and Blackstone) and our new Modified 6-point Activity Index. Weighted kappa statistics were used to estimate intra- and inter-observer variation. Results: The mean (SD) inter- and intra-observer weighted-kappa values for expert endoscopists were: Matts 0.76 (0.05) and 0.78 (0.07), Schroeder 0.74 (0.03) and 0.75 (0.03), Baron 0.61 (0.10) and 0.62 (0.07), Blackstone 0.57 (0.11) and 0.73 (0.05), and the Modified 6-point Activity Index 0.65 (0.05) and 0.79 (0.02); for trainee endoscopists they were: Matts 0.44 (0.09) and 0.41 (0.13), Schroeder 0.46 (0.07) and 0.48 (0.18), Baron 0.47 (0.05) and 0.46 (0.15), Blackstone 0.46 (0.07) and 0.51 (0.12), and the Modified 6-point Activity Index 0.54 (0.08) and 0.64 (0.02). The Matts and Schroeder indices gave a ‘good’ degree of concordance for expert endoscopists in terms of inter- and intra-observer agreements; this was not so evident with the Baron and Blackstone indices. For trainee endoscopists, all scores for inter- and intra-observer weighted kappa values using established indices were lower than for the experts. The degree of concordance using the Modified 6-point Activity Index was rated as ‘good’ for inter- and intra-observer agreements for expert endoscopists, and as ‘moderate’ for trainee endoscopists. Conclusions: Accurate assessment of UC disease activity from endoscopic findings benefited from experience. For expert endoscopists, the Matts and Schroeder indices proved the most reliable of the four established indices. Current endoscopic technologies may be adequate for assessing UC activity, particularly if modified to permit a finer classification of disease severity based of six grades, as with our newly-developed Modified 6-point Activity Index.

T1395 Adenoma Recurrence Rates in First-Degree Relatives of Patients with Colorectal Cancer. Do These Patients Need More Intensive Surveillance? Angel Ferrandez, Maria Badia, Pilar Roncales, Monica Polo-Tomas, Federico Sopena, Ricardo Sainz, Angel Lanas T1393 The Robotic Colonoscope E-Worm, a New Device to Perform Colonoscopy: Preliminary Report Giovanni Rubis Passoni, Roberta Barbera, Antonella Tauro, Cosentino Felice Colorectal tumor is the second cause of neoplastic mortality in males after lung cancer, and ranks the same in female after breast cancer. Among screening procedures conventional colonoscopy is considered the best available method, however it is invasive, it’s associated with procedural risks, usually needs conscious sedation or even deep sedation. The E-Worm is a new medical device for the diagnostic colonoscopy, it is the result of an italian academic research in the field of robotic biomimetics, it moves like a worm using two specific clampers for adhesion with intestinal mucosa. The light sources (LEDS) and the videocamera are inserted in the head of the E-Worm. This allows a live vision on the screen of the workstation like a normal colonoscope. The unique locomotion system with outstanding flexibility, able to follow every type of treedimensional shape, gives a new opportunity for a painless colonoscopy procedure. The flexibility together with the low force required to move the probe reduces the risk of any perforation. The Authors present their fist experience in performing colonoscopies using this new colonoscope. From December 2007 to November 2008 we performed 37 colonoscopies with the E-Worm. Patients were prepared with PEG as conventional colonoscopy. Cecal intubation was possible in 15 cases (40%), ileal exploration was performed in 1 patient with crohn’s disease (2%). The right colon was reached in other 7 patients (19%). No patients needed sedation. No complications occurred. Pathologies were found in 19 pts (51%). Evaluating the first 20 pts with the last 17 we saw an increase of cecal intubation rate from 35% to 48%. In spite of a lower definition resolution of endoscopic picture, the diagnostic yield was good, comparable to conventional colonoscopy. Our preliminary experience demonstrates that this new colonoscope allows good diagnostic procedures without any need of sedation. In our opinion the low cecal intubation rate could be related to the learning curve.

www.giejournal.org

Background: According to guidelines (Winawer S et al. CA Cancer J Clin 2006), colon surveillance in first-degree relatives (FDR) of patients with colorectal cancer (CRC) should be similar to patients without family history. However, surveillance intervals are mainly based on data on adenoma recurrence in average-risk patients or on sub-analysis derived from studies not specifically designed in high-risk patients. Evidence is scarce referring the adenoma recurrence rate in patients with family history of CRC. Aim: To investigate the adenoma recurrence rate in FDR of patients with CRC. Methods: We conducted an analysis of the colonoscopy and pathology reports of FDR from the colon cancer prevention program in high risk patients in our center, inserted in the regional program from Aragon, Spain. It is a prospective, multicenter program, in which FDR of patients with CRC are invited to colonoscopy screening after their familiar has been diagnosed. We analyzed the recurrence rate in patients with advanced (R10 mm or high grade dysplasia or villous architecture) and non-advanced adenoma who had a surveillance colonoscopy. Patients with at least one AA or R3 adenomas were considered as high-risk patients (HR) and the rest as low-risk (LR). Results: A total of 771 FDR had been screened so far. Among them 253 (32.8%) presented at least an adenoma at baseline colonoscopy and in 145 (57.2%) a surveillance colonoscopy was performed in the study period (2000-2006). Eighty (10.5%) patients were classified as HR according to baseline colonoscopy findings. Among them, surveillance colonoscopy (interval of 16.4  11.1 months) 41 (53.3%) had a normal (or with hyperplastic polyps), 30 (37.5%) had a recurrence of either AA or O 3 adenomas, and 10 (12.2%) had non-advance adenomas. A total of 65 FDR had a non-advanced adenoma at baseline colonoscopy. At surveillance colonoscopy (25.7  15 months), 9 (13.8%) patients presented an AA, 14 (21.5%) a non-advanced adenoma and 62 (64.7%) had a normal colonoscopy. No CRC was found in any patient. Among the 39 HR patients according to the surveillance colonoscopy, 12 (30.8%) had an AA in a second surveillance colonoscopy. Conclusions: Recurrence rates of AA in first-degree relatives of patients with colorectal cancer included in our study seem to be higher to that reported in average-risk patients. Our results would suggest a more intensive surveillance strategy in high-risk patients although no cancers were found. More studies are needed to confirm our results and to analyze the economic impact of a more intensive surveillance.

Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB285